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The Villa Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 29 June 2021

About the service

The Villa is a nursing home providing personal care to 32 people at the time of the inspection, some of whom were living with dementia. The service can support up to 38 people in an adapted building.

People's experience of using this service and what we found

People could not be assured the environment would be safe as the provider had not taken necessary action to carry out remedial work as identified in their own fire risk assessment. The undertaking of quality assurance checks did not identify areas where improvements were needed. Window restrictors were not tamper-proof placing people at risk of potential harm.

People could not be assured by the systems in place to assess and manage their safety. Accident and incidents were recorded and reviewed; however, the provider had failed to act after a resident had suffered a number of similar falls.

People's care plans were reflective of their current needs.

People were supported by enough staff who supported them in a timely manner and staff members received training on how to keep people safe from the risk of abuse.

People's medicines were managed effectively.

We found there was a positive culture shared between staff to promote good outcomes for people.

Managers and staff were open and honest. People, their relatives and staff had the opportunity to make changes to the service.

Staff worked in partnership with other healthcare professionals.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was good (published 26 February 2019).

Why we inspected

We undertook this focussed inspection due to concerns shared with us by the fire safety department. They raised concerns about the lack of management of fire systems to ensure the safety of people in an emergency. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has deteriorated to requires improvement.

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 coronavirus and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report.


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to keeping people safe, maintaining a safe environment and the provider’s monitoring of the provision of care 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 request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any co

Inspection areas


Requires improvement

Updated 29 June 2021

The Service was not always safe.

Full details are in the safe section below.



Updated 29 June 2021



Updated 29 June 2021



Updated 29 June 2021


Requires improvement

Updated 29 June 2021

The service was not always well led.

Full details are in the safe section below.