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Inspection Summary

Overall summary & rating

Requires improvement

Updated 14 August 2018

Our inspection of Salroyd Villa Residential Home took place on 30 May 2018 and was unannounced. At the last inspection in April 2017, the provider was in breach of legal requirements concerning safe care and treatment, meeting nutritional and hydration needs, need for consent and good governance. The service was rated as requires improvement. At this inspection, we found some improvements had been made however, more work was still required to achieve compliance with the regulations.

Salroyd 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.

Salroyd Villa is a large detached building. Salroyd Villa is registered to provide care and support for up to 16 people who have dementia. At the time of our inspection there were 16 people living at the home.

A registered manger was in place. 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. Staff knew how to recognise and report any concerns about people's safety and welfare.

Overall, there were enough staff deployed. However, 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 and staff had good knowledge of the medicine systems and procedures in place to support this. The support people received with their medicines was person centred and responsive to their needs.

We recommended the provider implemented a system to ensure food thickener was managed safely.

People were provided with care and support by staff that had received appropriate training. Staff told us they had received induction and training relevant to their roles.

People were supported with their health care needs. We saw a range of health care professionals visited the service when required and people were supported by staff to attend health care appointments.

People’s care plans were not always detailed enough and this created a risk they would not consistently receive appropriate care which met their needs.

The service was acting within the legal framework of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). 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's nutrition and hydration needs were well catered for. People received a range of food which met their individual needs. However, nutritional risk assessments and care plans required some improvements.

Staff knew people well. People felt they participated in planning their care. Care records included information about preferences, likes and dislikes.

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 activities.

Information about complaints was displayed in the home. People told us the manager was approachable and listened to them. People were supported to share their views about the service.

Staff told us they felt supported in their roles and their views were listened to through supervision and team meetings.

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 make the required improvements.

We found three breaches of regulations in relation to the fit and proper person employed, need for consent, and good governance. We are considering the appropriate regulatory response to o

Inspection areas


Requires improvement

Updated 14 August 2018

The service was not always safe.

Medicines were managed safety.

There were enough staff available to meet people’s needs.

The provider did not always follow robust recruitment procedures; some checks such as satisfactory references had not carried out before new staff started work.

Staff knew how to recognise and report concerns about people’s safety and welfare.


Requires improvement

Updated 14 August 2018

The service was not always effective.

Improvements were required to documentation of people’s food and fluid requirements to provide assurance that people’s nutritional needs were met.

Staff received a range of training and support relevant to their role. Staff felt well supported by the service.

The service worked effectively with a range of health care professionals to ensure people’s needs were met.

The service was compliant with the requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Consent was not sought correctly for some people.



Updated 14 August 2018

The service was caring.

Staff knew people and their care and support needs.

People provided positive feedback about the standards of care, telling us staff treated them with dignity and respect.

People were comfortable in the presence of staff and good relationships had developed.


Requires improvement

Updated 14 August 2018

The service was not always responsive.

Care records and people's assessed needs were regularly reviewed, but lacked evaluation and insight into the success of the plan.

People had access to a range of activities.

People received person centred care, which focused on their individual needs.

People knew how to make a complaint if they needed to.


Requires improvement

Updated 14 August 2018

The service was not always well led.

People were very complimentary about the service and everyone we spoke with said they would recommend it.

Most people, relatives and staff told us they felt the registered manager was approachable and acted quickly in response to any concerns or issues.

Improvements were needed to the processes for checking the quality and safety of the services provided.