Archived: Rose Villa Nursing Home

Updated 27 July 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 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 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 16 and 17 June 2016 and was unannounced. The inspection was carried out by two inspectors.

Prior to the inspection, we met with representatives from the Local Authority. The Local Authority informed us that there was a suspension on placements at the home. The information they shared with us was used in the planning of the inspection.

We spoke with the manager, six members of care staff and a registered nurse. We spoke with one relative and four people who lived at the home and a representative from the local Clinical Commissioning Group. We also contacted representatives from the local authority and the fire service during the course of the inspection, who arrived on site to conduct their own investigation into the circumstances we had found. Due to concerns bought to our attention regarding infection control, we also opened up this key line of enquiry and spoke with an infection prevention nurse following the inspection.

We carried out a number of observations, including observing manual handling techniques and a Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk to us.

We looked at the care records of six people, eight medication administration records, records of accidents and incidents, health care records, recordings of handovers, and a number of policies and procedures.

Updated 27 July 2016

We carried out an unannounced comprehensive inspection of this service on 6 October 2015, at which a breach of legal requirements was found. This was because systems and processes were not in place to effectively assess, monitor and mitigate the risks relating to the health, safety and welfare of people living at the home, including the maintenance of accurate records in respect of people living at the home.

We carried out a further focussed inspection of the service on 21 April 2016 to check that the provider had made and sustained the improvements they had told us they would make. At this inspection we found that the provider had failed to make the improvements they told us about. We also identified some other concerns which we raised with the provider on the day.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediately action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to being the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

Rose Villa Nursing Home provides accommodation and nursing care for up to 27 older people or people with physical disabilities. At the time of our inspection, 11 people were living at the home.

There was a manager in post, but she had recently been appointed and was not registered with the Care Quality 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.

Fire risk assessments were not in place to ensure staff were aware of their roles and responsibilities in the event of a fire. The call bell system on the first floor was not fit for purpose and did not enable staff to respond to people’s needs in a timely manner.

Not all risks assessments in place for moving and handling involving equipment had been completed in line with the manufacturer’s guidelines, leaving people at risk of harm.

People’s medical conditions were not always treated appropriately by the use of their medication.

People were not adequately protected from the risk of infection control and requirements of a recent infection prevention action plan had not been met.

People were not supported in a timely manner as staff were required to cook meals as well as care for people. A shortage of nursing staff meant the manager regularly worked on shift to cover staff absences and was unable to drive forward the improvements required in the home.

Staff did not receive an induction and training that provided them with the knowledge and skills they required to safely meet the needs of the people they supported.

People did not receive a choice of meals and the quality of food provided was poor and not nutritious.

Staff gained people’s consent before providing them with care and support, but lacked knowledge of legislation protecting people’s rights.

People were supported to access healthcare services, but some staff failed to pass on information regarding people’s healthcare needs to new staff coming onto shift.

People were supported by staff who were caring and kind, but people’s dignity was not always maintained.

People were not involved in the planning of their care or asked how they preferred to be supported or spend their time. There were no activities taking place in the home and no stimulation for people on a daily basis.

There was a system in place to record people’s complaints, but there was no information available advising people how to do this and people were not aware of it.

People spoke highly of the manager and felt supported by her, but felt that she lacked support from the provider.

The provider had failed to take responsibility for the day to day running of the home and to offer support to the manager and the staff. The provider had failed to ensure the requirements of the action plan that was in place had been fully met.

We found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.