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The Villa Requires improvement


Inspection carried out on 20 May 2021

During an inspection looking at part of the service

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 carried out on 15 January 2019

During a routine inspection

The Villa is a residential care home that provides nursing and residential care up to 38 people. The home has a bungalow in the grounds that is used to support those who are planning to live independently in the community. At the time of inspection there were 32 people living in the home with four people in the bungalow. The building was in the process of undergoing a large refurbishment process.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

During the previous inspection the Effective domain had been rated as Requires Improvement as documentation relating to assessments and decisions regarding mental capacity had required improvement. At this inspection we found that the service had improved and the service was now working within the principles of the MCA and DoLS. 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 support this practice.

At this inspection we found the service Good.

The home has a registered manager who was supported by a deputy manager and the provider. 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.

Medications were safely managed and lessons were learnt from any mistakes. People who lived in the home and relatives gave positive feedback about the home and the staff who worked in it. The home had a relaxed feel and people could move freely around the service as they chose. People were able to have control over their lives and participate in activities they enjoyed.

Care plans and risk assessments were person centred and detailed how people wished and needed to be supported. They were regularly reviewed and updated as required, with input from people and their families. Care plans showed that people's GPs and other healthcare professionals were contacted for advice about their health needs whenever necessary. We saw the service had responded promptly when people had experienced health problems.

The registered manager and provider used different methods to assess and monitor the quality of the service. These included regular audits of the service and staff meetings to seek the views of staff. The staff team were consistent and the providers were also involved in the running of the service.

Staff were recruited safely, received a robust induction and suitable training to do their job role effectively. All staff had been supervised in their role.

The home had carried out various checks to ensure the environment was safe and infection control processes were in place.

Further information is in the detailed findings below.

Inspection carried out on 21 July 2016

During a routine inspection

This unannounced inspection took place on 21 July 2016. The inspection team consisted of two inspectors. The CQC registered the service on 18 February 2015 and this was the first comprehensive inspection.

The Villa provides accommodation for people who require nursing or personal care and/or treatment of disease, disorder or injury. The home can accommodate up to 33 people and on the day of the inspection, there were 32 people living at the service.

There was a registered manager in place for the service. 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 were safe and risks were minimised by staff who understood how to keep people safe and identify and manage risks and safeguarding concerns. Staff employed by the service had pre-employment checks to ensure they could safely work with people. There were enough staff to provide safe and effective support. People had their medicines administered safely.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and report on what we find. The service did not have systems in place to assess people’s mental capacity in line with the principles of the act. Where required the registered manger made applications to the authorising agencies for a DoLS. Staff understood the principles of the MCA and DoLS and could apply these when delivering care and support; however, the documenting of assessments and decisions required improvement.

People had support from trained staff who understood how to meet their needs and had the required skills to provide effective support. People had a healthy diet and could access food and drinks as and when they wanted. There was a choice of meals, which people enjoyed, and they could access support, as they needed it. People had access to health professionals and detailed care plans to support them to maintain their health and wellbeing.

People had support to develop positive relationships with other people living at the home and the staff. Staff respected people’s privacy and dignity when providing care and support and encouraged people to be independent. People were involved in guiding their own care and staff encouraged them to be involved in their care delivery.

People’s care and support was personalised and responsive to their needs. Staff understood how to meet people’s needs and preferences and offer consistent support. Staff could follow detailed care plans, which supported people to receive responsive care and were, reviewed when things changed. People had a range of different things to choose from when deciding how to spend their time.

People could give their feedback about the service through formal meetings and through discussions with staff on a day-to-day basis. People felt listened to and their relatives felt involved. People and their relatives understood how to make a complaint and felt the registered manager would address their complaints and provide a response.

People were involved in the delivery of the service and the registered manager encouraged an open culture. The registered manager provided leadership for the service; they had support from team leaders and nurses in managing the home. The registered manager had systems in place to monitor quality and could show how these led to improvements.