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Rose Villa Nursing Home Good

Inspection Summary

Overall summary & rating


Updated 20 March 2018

This inspection took place on 12 February 2018 and was unannounced. At the last inspection in January 2017, the provider was in breach of three regulations of the Health and Social Care Act 2014. These related to risk management in safe, consent in effective, and governance in well-led. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when, to improve the key questions of safe, effective and well-led to at least good. We checked to see that the action plan had been completed and found improvements had been made in all three areas. The provider was now compliant with the three breaches of regulations.

Rose Villa is registered to provide care for 36 people who need nursing care and who may be living with dementia. Fifteen of the 36 placements are allocated as an interim care service for those people who may need support to prevent hospital admission or rehabilitation following discharge from hospital. The building is two large Victorian houses and has three floors serviced by a passenger lift. There are bedrooms for single and shared occupancy on each floor, and a large communal space divided into two lounges and a dining space on the ground floor.

Rose Villa is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Governance of the service had improved. The quality assurance system consisted of audits, checks, observation of staff practice, meetings and surveys. The audits were completed on a range of topics and shortfalls identified from them and from the meetings and surveys were addressed in action plans. The provider’s representative completed visits and spot checks of the service; they spoke to people and completed a check of the environment. This helped to ensure the provider had oversight of the service.

We saw risk management had improved. A range of risk assessments were completed and these were checked more frequently and kept up to date. A new heating system had been installed which had removed the risk of cold bedrooms and the need for electric heaters.

We found the registered manager and staff had a much improved understanding of mental capacity legislation and the need for consent. People had assessments of capacity and best interest decisions made on their behalf if they lacked capacity; documentation regarding best interest decisions had improved. Appropriate applications had been made to the local authority when people’s liberty was deprived due to their lack of capacity and need for continual supervision.

At the last inspection, we made a recommendation about ensuring care plans were more person-centred and monitoring charts were accurate. Whilst this had improved in several of the care plans we assessed, there remained some shortfalls and we have made a recommendation that these improvements continue.

Staff knew how to safeguard people from the risk of abuse and harm. They had completed safeguarding training and had policies and procedures to guide them. They were clear about the alerting procedures to the local safeguarding team.

Staff were recruited safely and in sufficient numbers to meet people’s needs. A health professional told us some people had mentioned they had various waiting times when they used the call bell. This was discussed with the registered manager to address.

People told us staff were kind and caring and respected their privacy and dignity. People could

Inspection areas



Updated 20 March 2018

The service was safe.

The management of risk had improved and assessments had been carried out to ensure any areas that posed a risk to people could be minimised.

Staff knew how to safeguard people from the risk of abuse and harm. They had completed training and had procedures to guide them.

Medication as was managed safely and people received their medicines as prescribed.

Staff were recruited safely and were employed in sufficient numbers to meet people�s needs.

The service was clean and tidy and staff knew how to prevent the spread of infection.



Updated 20 March 2018

The service was effective.

There had been improvements in staff�s understanding and implementation of mental capacity legislation. When people lacked capacity to consent to care, best interest decisions were made in consultation with relevant people.

People�s health and nutritional needs were met. They had access to a range of health professionals when required. Menus provided choices and alternatives and people told us they liked the meals.

Staff had access to training, supervision and appraisal to help them feel confident when supporting people.



Updated 20 March 2018

The service was caring.

People told us the staff approach was kind and caring. We observed this in practice and also saw staff maintained people�s privacy and dignity.

People were provided with information about the service available to them and staff gave explanations about care tasks prior to carrying them out.

Staff maintained confidentiality and personal records were stored securely.


Requires improvement

Updated 20 March 2018

The service was not consistently responsive.

There have been improvements in care plans, and summaries of people�s care needs contained more information. However, some information was missing in two of the care plans we looked at and the recording of monitoring charts was inconsistent.

The provision of activities had improved and was much more structured. People told us there was sufficient activities and meaningful occupation for them.

There was a complaints procedure and people who used the service felt able to raise concerns. Staff knew how to manage complaints.



Updated 20 March 2018

The service was well-led.

The quality monitoring system had improved with audits and checks identifying areas to be addressed. Any shortfalls were included in action plans. There were meetings and surveys as part of quality monitoring.

The registered manager encouraged an open culture where people felt able to express their views.

The registered manager had developed good relationships with other professionals who supported people who used the service.