We carried out a review of the data available to us about West Villa Residential Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about West Villa Residential Home, you can give feedback on this service.
West Villa Residential Home is a residential care home providing people with accommodation and personal care. The service is registered to support up to 32 people. At the time of the inspection there were 29 people living at the service. The service provides support to adults including people with dementia.
West Villa Residential Home accommodates people in one adapted building. There are bedrooms across three floors with communal living areas on the first floor.
People’s experience of using this service and what we found
Risk assessments at the service had not all been reviewed at the time of the inspection. The registered manager updated these during the inspection and discussed upskilling additional staff to assist with the completion of these records. People told us they felt safe and received their medicines on time. Accidents and incidents were appropriately recorded and reviewed to identify trends and learning, where possible. The service had recently switched to an electronic care planning system where care records were updated by staff on hand held devices. Staff spoke positively about the use of these devices. The registered manager will be further updating these systems to ensure all planned care is recorded accurately. For example the administration of thickener did not always state the consistency. People told us they felt safe and supported by staff.
Staff told us they felt supported by the registered manager and the provider. The registered manager completed regular audits of the service. Both the registered manager and the provider completed spot checks at the service to assess the quality of the service. The service responded appropriately to complaints. Staff had regular supervisions and felt able to discuss concerns with the management team. The local authority and a visiting health care professional gave positive feedback about the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was requires improvement (published 31 March 2020). At our last inspection we recommended the provider improved cleaning regimes to ensure the elimination of unpleasant odours. At this inspection we found an appropriate cleaning regime in place, the provider had changed their cleaning products and there were no unpleasant odours during the inspection.
Why we inspected
This inspection was prompted by a review of the information we held about this service. We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
West Villa is a residential care home providing personal care to 22 people aged 65 and over at the time of the inspection. The service can support up to 32 people.
The home is over three floors, with communal living spaces on the first floor. People’s bedrooms are on all three floors.
People’s experience of using this service and what we found
People received safe care. Improvements had been made to ensure risks were identified and mitigated. Assessments of people’s needs considered individual risks and included details about what equipment they needed to help them stay safe. Staffing was organised so people received the support they needed. Systems and processes were in place to support people safely with their medicines. Accidents and incidents were more closely monitored and analysed through clearer systems and processes which had been introduced since the last inspection. We made a recommendation for the provider to improve cleaning regimes to ensure the elimination of unpleasant odours.
There were systems in place to support staff to provide effective care. The registered manager ensured staff received appropriate training, supervision and appraisal. Teamwork was effective and a clear management structure supported staff in their work. Roles and responsibilities were understood by staff and communication with one another supported people’s needs.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People gave their consent to care in line with current legislation.
Staff had good relationships with people and were kind, patient and caring in their approach. People were treated respectfully and their independence was encouraged. Activities were planned and visitors welcomed to ensure people were not isolated. Care plans had been rewritten since the last inspection and were clear and concise. The registered manager was continuing to add detail to these in order to ensure they reflected people’s individual social needs.
Changes had been made in the way the service was led and managed. A new manager was in post and staff were confident improvements were being made. Systems and processes to monitor the quality of the provision had been revised and were being embedded. There was clearer oversight by the provider to develop an open and transparent culture and to ensure the quality of the care delivery. The service was showing clear and significant signs of improving, although at the time of the inspection the provider was not able to demonstrate how improvements would be sustained.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was inadequate (published September 2019) and there were multiple breaches of regulation. The service has been in Special Measures since September 2019. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of the regulations. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
West Villa is a residential care home providing personal care to 29 people aged 65 and over at the time of the inspection. The service can support up to 32 people.
The home is over three floors, with communal living spaces on the first floor. People’s bedrooms are on all three floors.
People’s experience of using this service and what we found
People’s care was not provided safely. Individual risks to people and risks within the premises were not identified, mitigated or monitored. People who required support with moving and handling did not have individual equipment and no assessments had been carried out to ensure equipment was safe for them to use. Medicines were not managed safely, which put people at risk of harm. Fire safety was not given high priority and people’s individual emergency evacuation plans were not accurate. Recruitment processes were not always robust and there were insufficient numbers of suitability trained staff, especially at night. Accidents and incidents were not monitored and safeguarding procedures were not always followed.
People’s needs and choices were not assessed thoroughly. There were poor systems in place to support staff to provide effective care. Staff did not have appraisal or consistent supervision and there were no competency checks to make sue they had the right knowledge and skills to meet people’s needs. Consent to care and support was not consistently obtained, monitored or reviewed in line with legal requirements and national guidance.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
Care and care documentation was not person-centred. Activities took place but some people were bored and at risk of social isolation.
Management systems were weak and there was a lack of oversight of the quality of service delivery. Audits were being done but they lacked rigour and had not successfully addressed the breaches since the last inspection. There were gaps in actions, dates and signatures. Accidents and incidents were not always reported to CQC as required.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was Requires Improvement (published 14 August 2018).
We found four breaches of regulations relating to safe care and treatment, need for consent, good governance and fit and proper persons employed.
At this inspection not enough improvement had been made and the provider was still in breach of these regulations. We identified four further breaches of regulations relating to person-centred care, safeguarding service users from abuse and improper treatment, premises and equipment and staffing.
Why we inspected
This was a planned inspection based on the previous rating and to follow up on action we told the provider to take at the last inspection.
The inspection was prompted in part due to concerns received about staffing and safe care and treatment. A decision was made for us to inspect and examine those risks.
The overall rating for the service has changed from Requires improvement to Inadequate. This is based on the findings at this inspection.
We have found evidence that the provider needs to make improvement. Please see all sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for West Villa on our website at www.cqc.org.uk.
Enforcement
We have identified eight breaches in relation to: safe care and treatment; need for consent; good governance; fit and proper persons employed; person-centred care; safeguarding service users from abuse and improper treatment; premises and equipment; and staffing at this inspection.
Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.
West 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.
West Villa is a private care home. It is a large detached building. West Villa is registered to provide care and support for up to 32 people who have mental health needs or physical disabilities related to the aging process. At the time of our inspection there were 29 people living at the home.
A registered manager was not in place. However, a new manager had been appointed and had submitted an application to become registered with the Commission. 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.
People told us they felt safe and staff knew how to recognise and report any concerns about people's safety and welfare.
Overall, there were enough staff deployed. Not all the required checks were done before new staff started work to help to protect people. Staff were trained to meet people's needs.
Medicines were managed safely.
Individual risks to people's health and welfare were not always identified and managed. Their care plans were not always detailed enough
and this created a risk they would not consistently receive appropriate care which met their needs.
The home was clean and well maintained. Plans were in place for refurbishment to make the home more dementia friendly.
We found people's capacity to consent to their care and treatment was assessed. However, when people lacked capacity the correct processes were not always followed to ensure those making decisions on their behalf had the legal powers to do so.
People told us they liked the food. People were offered a variety of food and drink, which took account of their likes and their medical, cultural and religious needs.
People were supported to meet their healthcare needs and had access to a range of healthcare professionals. People's needs were assessed. However, care plans were not always in place and this created a risk they would not receive appropriate care, which met their needs.
People were treated with respect and kindness and were supported to maintain their independence. People were given the opportunity to take part in a variety of social activities.
Information about complaints was displayed in the home. Most people told us the manager and provider was approachable and listened to them. People were supported to share their views about the service.
We found the providers quality-monitoring systems were not always working as well as they should be. We were assured of the provider's commitment to making the required improvements.
We found four breaches of regulations in relation to the management of consent to care and treatment, fit and proper person employed and good governance. We are considering the appropriate regulatory response to our findings.
There was a manager at the service who had submitted an application to register with the Care Quality Commission, at the time of the inspection, the manager’s registration was in the process of being completed. 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.
West Villa is a private care home, which has been owned and managed by the same family for over twenty- five years. It is a large detached building, situated near local amenities. West Villa is registered to provide care and support for up to 32 people who have mental health needs or physical disabilities related to the ageing process and supports people who are over 60 years of age. At the time of our inspection there were 31 people living at the home.
The home provided 32 single rooms 22 of which had en-suite facilities. The building and furnishings were maintained and decorated and environmental checks were up-to-date. The home was clean and free from unpleasant odours and systems were in place for the prevention and control of infection.
Care staff had a good understanding of safeguarding procedures, how to identify signs of abuse and what action they would take to protect vulnerable people in their care.
From our observations we saw there were sufficient, appropriately trained care staff available to support people to meet people’s needs safely. Recruitment checks had been carried out on all care staff to ensure they were suitable to work in a care setting with vulnerable people. Care staff had received an induction and had undertaken a variety of training to ensure they had the skills and knowledge required for their roles. Care staff received regular supervision which ensured that the standard of their work was monitored.
Medicines were stored correctly and administered by care staff who had received appropriate training and been assessed as competent to safely administer medication. The systems for recording medicines in the service needed to be improved to ensure medicines were managed safely. We have made a recommendation about the management of some medicines.
Although the service was in the process of updating and reviewing all risk assessments and care plans they did not consistently reflect the level of identified risk for people. We have made a recommendation about speeding up the process of reviewing risk assessments and care plans.
People were supported to eat and drink sufficient amounts to meet their needs and residents were actively involved with planning the choice of food offered. People’s weight were monitored effectively and concerns were addressed with health professionals. People were supported to maintain good health and where needed specialist healthcare professionals were involved with their care.
We observed care staff were kind and caring. Through talking with care staff and residents we found people were treated as individuals and that care staff responded to their needs in a caring and dignified manner. Care staff offered encouragement and spoke in a positive way to residents in order to help improve their self-esteem.
Activities were at the heart of the daily life of West Villa and a range of varied activities, suggested by residents, was available.
People using the service, relatives and healthcare professionals were able to express their opinions about the service through regular surveys about the quality and standard of care provided. The home had a complaints procedure and people we spoke with knew how to make a complaint if they needed to.
Quality assurance processes such as audits were in place to ensure that the service delivered a high standard of care, although not fully robust, in line with the newly appointed registered manager.
Care staff worked well together and there was a positive culture among staff. The management team was forward thinking and keen to promote West Villa as a happy and positive place in which people could live in. Care was person centred and care staff understood people’s individual needs and their likes and dislikes.
This inspection took place on 20 and 21 October 2015 and was unannounced. Our last inspection took place in February where we found there were multiple breaches of regulations. We found at this inspection the provider had made significant improvements to the quality of the service and had addressed all of the concerns highlighted previously.
There was a manager at the service who had submitted an application to register with the Care Quality Commission, but at the time of the inspection, the manager’s registration was not complete. 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.
We found that the provider had addressed all issues relating to the legal requirements relating to Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA) 2005.
There was significant evidence of widespread improvements to the quality of the provision. The provider had addressed all areas of concern identified at the last inspection. There was marked improvement to the management, staff morale and the culture within the home.
The provider had made investments to the fixtures and fittings in the home to help eliminate bad odours. We saw that the home was very clean and there were no malodours. Cleaning took place constantly throughout the day. Staff practised good hand hygiene and using personal protective equipment appropriately.
We saw that there were sufficient numbers of suitably trained and skilled staff available to meet people’s needs safely. Staff were knowledgeable about people’s needs and had received updated training in many areas.
Risk assessments were detailed and known by staff. Accidents and incidents were closely monitored, although the cause of some accidents was not always investigated thoroughly to prevent a repeat occurrence.
People’s weight was more effectively monitored and there was improvement in the quality and availability of food and drink for people since the last inspection.
Staff were very kind, patient and caring and demonstrated a good regard for people’s privacy and dignity.
Care was person centred and staff understood people’s individual needs and preferences, with regard for people’s personal life histories.
Systems to assess and monitor the quality of the provision were developing, although not fully robust, in line with the new appointment of the manager.
We did not identify any breaches of regulations at this inspection.
We have considered and concluded our enforcement actions in relation to the regulatory breaches identified at the previous inspection as we are satisfied the provider has addressed all areas of concern.
The inspection took place on 7, 12 and 20 February 2015 and was unannounced.
The service provides accommodation for up to 32 older people. West Villa Residential Home is situated in a residential area of Wakefield.
At the time of our inspection there was a registered manager in post, who was also the provider. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.
People told us they felt at home and were happy and content. People said they felt safe and staffing levels were good enough to meet their needs. Relatives told us they were happy with the care provided for their family members.
There were sufficient numbers of care staff and ancillary staff on duty to be able to support people’s care. However care staff did not appear to have the skills required to support people safely and in a way that met their needs.
Communal areas and some bedrooms smelled strongly of urine and staff did not give prompt attention to people’s personal hygiene needs.
Individual risks to people were not safely managed and staff were not proactive in recognising concerns about people’s safety and welfare.
People were not always treated with respect and their dignity and their rights were not adequately promoted. Staff did not show positive regard for people’s abilities and they did not empower them to maintain their independence and be involved in decisions about their care. People were not effectively supported to have enough to eat and drink.
Staff lacked understanding of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The Deprivation of Liberty Safeguards (DoLS) are part of the Mental Capacity Act 2005. They aim to make sure that people in care homes, hospitals and supported living are looked after in a way that does not inappropriately restrict their freedom.
Staff had some opportunities for regular training, although there was no professional development to enhance their skills and knowledge of working with the particular needs of people in the service, such as those living with dementia.
People’s care records did not provide detailed or accurate information for staff to be able to support their individual needs safely.
Systems to monitor and review the quality of the provision were not robust and the registered manager did not sufficiently maintain an overview of the service.
Some of the issues identified at this inspection had been raised with the registered manager at the previous inspection, and insufficient action had been taken to address these.
We shared our concerns with the local authority, commissioners, safeguarding and the infection control team.
You can see what action we told the provider to take at the back of the full version of the report.
We carried out this inspection under Section 60 of the Health and Social Care Act 2012 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2012 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.
The inspection was unannounced. The last inspection was in August 2013 and there were no breaches in the regulations in the areas we looked at.
West Villa Residential Home provides accommodation and personal care for up to 32 older people, some of whom may also have mental health issues and dementia.
A registered manager was in place, who was also the provider. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.
Staff were kind and caring and attentive to people’s needs. Relatives spoke positively about the quality of care for their family members. This was confirmed during our observations of people’s care.
People told us they enjoyed the food and we found the staff discussed all dietary needs with the chef, who prepared meals according to people’s tastes and preferred quantities.
Assessments of people’s needs and plans of their care were not always effective and individual risk assessments were not always fully in place or up to date.
Necessary safety checks of the lift had not consistently been carried out. Documentation relating to the running of the home, such as policies, procedures, risk assessments and maintenance records were not always in place or up to date.
We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and of the Health and Social Care Act 2008 (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.
People we spoke with were happy with how they spent their days. Whilst we were there a person went to a local day centre. One person told us they had watched Casino Royale the previous evening and had enjoyed it. There were regular activities organised for people who wanted to be involved. One person told us, "Staff take me out to the shops."'
There were effective systems in place to reduce the risk and spread of infection. We found regular cleaning schedules.
We spoke with five members of staff who told us the training they received helped them to have the skills to deliver good care.
The home had systems and audits in place to monitor the quality of the service they provided. Records included monitoring the home's environment, care plan reviews, medication reviews, mattress audits and maintenance of the building.
People told us they feel safe and like the people caring for them.
Positive relationships were observed being fostered between people living in the home and those caring for them. And their care needs were observed being met in a relaxed and unhurried manner. People told us they like the people caring for them.
The needs of people we could not communicate with were observed to be met in a relaxed and unhurried manner and positive relationships were observed between those living in the home and those caring for and supporting them. People told us they like the people caring for them as they help them do things.
People told us they feel supported and liked the people caring for them. People we could not communicate with were observed to be relaxed and comfortable.
People say they like living in the home. One person said 'If they have any concerns they can tell someone and its sorted' Another says the staff listen to what they have to say and things get changed' One person said they 'feel very safe and well cared for'. People we could not communicate with appeared to be happy, very relaxed and comfortable. One visiting relative said they are kept informed about their relatives' progress and if they have any issues they are dealt with immediately.
People say they like the people caring for them. One person said the carers are very good and very caring. Another says 'there is always someone there when you need them'. One visiting relative said the carers are excellent and nothing is to much trouble. They said they are very happy with the staff in the home.
People say they like the people caring for them. Some people we could not communicate with appeared to be happy and positive relationships were observed being fostered between those living in the home and those caring for them. One person said the staff are very good and listen to what they say. One visiting relative said the staff are always very courteous and welcoming.
People living in the home say they like the people caring for them. People we could not communicate with appeared to be relaxed and comfortable with those supporting them. One visiting relative said they feel they are happy with the care and support their relative receives.