We carried out a review of the data available to us about Salroyd Villa 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 Salroyd Villa, you can give feedback on this service.
Salroyd Villa is a residential home situated in Bradford. The home provides accommodation and personal care for up to 16 older people and people living with dementia. At the time of the inspection there were 13 people living at the home.
People’s experience of using this service and what we found
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems supported this process. Improvements were needed to documentation to fully evidence compliance with the Mental Capacity Act (MCA). We have made a recommendation about updating documentation to reflect people’s involvement.
People’s care needs were assessed, and they received good quality person centred care from staff who knew them very well. People and relatives told us they thought the service was safe. They praised the standard of care at the home and described staff as kind and caring. One relative said, “They [staff] are more than caring, they go the extra mile.”
Medicines were managed safely. People’s health and dietary needs were met and there were close links with health professionals and other agencies.
Staff were knowledgeable about people and the topics we asked them about. They received a range of training, supervision and appraisal.
The registered manager provided the home with leadership and promoted a strong team culture. They maintained good oversight through communication with people and the team and a detailed schedule of audits. They were passionate about continuing to improve the quality of the service. The atmosphere in the home was warm and inclusive.
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) and there were multiple breaches of regulations. 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 regulations.
Why we inspected
This was a planned inspection based on the previous rating.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Salroyd Villa Care Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
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 our findings.
The inspection was unannounced and took place on 19 and 26 April 2017. The management team were not available on the first day of our inspection, so we returned a week later to check documents which only management were able to access. On the days of the inspection, 15 people were living in the home.
Although the home had been operating for many years, in September 2016 changes were made to the partnership running the home meaning the home was re-registered with the Commission in its current form. As a result the service had not been previously inspected under this registration.
The current registered manager, who was also a partner in the business, and several other staff had also been at the home for many years under the previous registration. 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 rated the provider ‘Requires Improvement’ overall. This was because we found several areas of concern relating to the ways medicines were managed, a lack of working to the Mental Capacity Act (MCA), a lack of evidence people’s nutritional needs were being met and lack of robust governance systems. We also identified some good areas of practice. People, relatives and health professionals spoke positively about the home. They said that that the home provided good quality care in a friendly environment. Care was personalised and staff knew people well.
Medicines were not always managed in a safe and proper way. We were unable to confirm people had consistently received their medicines as prescribed as records were not consistently completed and a full balance of medicines in stock was not always kept.
People said they felt safe living in the home. Staff understood how to keep people safe from abuse.
Overall staffing levels were appropriate within the home, although staff were stretched when management were not present within the building. Safe recruitment procedures were in place to help ensure people were of suitable character to work with vulnerable people.
Risks to people’s health and safety were assessed and control measures such as specialist equipment were sourced to protect people from harm.
The premises were homely and kept clean and personalised to people’s individual requirements. We found some risks associated with the premises which the provider had rectified by the 2nd day of our inspection.
Staff received a range of training and support relevant to their role. People said staff had a good knowledge of them and how to provide effective care.
The service was not consistently compliant with the legal framework of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) as DoLS conditions had not been met.
We concluded people’s nutritional needs were not always met, as appropriate action had not always been taken when people were losing weight.
Staff were kind and caring. Good, positive relationships had developed between people and staff. Information on people’s past lives had been obtained to help provide personalised care and support.
People were encouraged to remain independent and help out around the home where possible.
People felt listened to and their views and opinions were used to shape care and support arrangements.
People’s needs were assessed and plans of care put in place. People, relatives and health professionals said care met people’s individual needs.
A programme of activities was in place. These included regular visitors such as entertainers, regular events and trips out into the community.
A system was in place to log, investigate and respond to complaints. No recent complaints had been received about the service and people were very satisfied with the home.
We found a positive, caring and person centred atmosphere within the home. The management team were ‘hands on’ and people and relatives spoke highly of them.
Audits and checks were carried out. Some of these needed to be more robust to prevent some of the concerns we identified from occurring.
People’s feedback was used to make changes to the service for example around activity provision.
We found four breaches of the Health and Social Care Act (2008) Regulated Activities 2014 Regulations. You can see what action we asked the provider to take at the back of the full version of this report.