Background to this inspection
Updated
12 March 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
Inspection team
The inspection team consisted of two inspectors on the first site visit. An inspection manager and an inspector attended the second site visit.
Service and service type
Moor Villa Farm is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
The registered manager was not based at the service and had taken a step back from the role in May 2021. An acting manager was supporting the service.
Notice of inspection
This inspection was unannounced on both site visits.
What we did before the inspection
We reviewed information we had received about the service since their registration with CQC. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all this information to plan our inspection.
During the inspection
We gave people the opportunity to speak with us about their experiences of the care provided. We spoke with five members of staff including the provider, registered manager, acting manager and support workers.
We reviewed a range of records. This included two people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.
Updated
12 March 2022
About the service
Moor Villa Farm is a residential care home which was providing care to three people at the time of the inspection. The service specialises in providing recovery and rehabilitation for up to five younger adults with complex mental health difficulties.
People’s experience of using this service and what we found
People were not receiving a service that provided them with safe, effective care. Risks associated with people's behaviours were not managed safely. Risks within the environment were not effectively mitigated which meant people were placed at risk of significant harm.
Medicines were not always administered as prescribed and infection control procedures did not support people to remain safe during the pandemic. Recruitment practices were robust.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support. The provider was not following proactive best practice models to reduce the need for restrictive interventions.
We found systems and processes used to ensure the service was running safely were not effective. We observed a lack of leadership, direction and oversight. The registered manager did not oversee the day to day running of the service and told us they rarely visited the service. An acting manager supported staff and people, but they lacked understanding of the importance of maintaining a safe environment for people.
The provider’s quality assurance systems had failed to identify significant risks to people. The inspection team identified a number of serious risks within the environment. The provider and registered manager were asked to address these immediately. We revisited the service to check on improvements that the provider told us they had made. Sufficient action had not been taken to ensure people using the service were safe. The provider then made the decision to close the service.
For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 25 September 2020and this is the first inspection.
Why we inspected
The information CQC received about the incident indicated concerns about the management of ligature risks. This inspection examined those risks.
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 COVID-19 and other infection outbreaks effectively.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
Enforcement
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 the safety of people and management oversight at this inspection.
We recognised that the provider had failed to ensure risks to people were effectively, assessed, managed and mitigated. This was a breach of regulation and we issued a notice of decision to impose conditions upon the providers registration.
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.