The Villas Care Homes Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the cleanliness, maintenance and oversight of the premises and equipment.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty.

Although staff understood their responsibility to report accidents and incidents, and these were reviewed individually, the provider did not carry out any overarching analysis. As a result, patterns and recurring issues were missed, and opportunities to learn and embed safer practices were lost. For example, when people fell, there was no consideration of wider environmental hazards. Leaders acknowledged this gap and stated that a new process would be introduced to ensure monthly trend analysis would be conducted going forward.

Health and safety risks which had been raised by internal and external stakeholders had not been promptly addressed. For example, mould in the laundry room had been identified through the providers own systems, and the local hospital infection, prevention and control (IPC) team in January 2025, however remained an issue at the time of our inspection.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They supported people to make sure there was continuity of care, including when people moved between different services. For example, the provider had recently worked with 1 person and the relevant professionals, including advocacy services, involved in their care to move onto more independent living. Where people had difficult experiences in previous settings, care plans clearly detailed risks, life histories and relevant information to help staff have a comprehensive understanding of the person’s needs and potential triggers. This helped reduce the likelihood of distress and disruption during the person’s transition into the service.

Systems and process were not always effective to ensure people were fully protected from the risk of abuse. Whilst we found no evidence concerns about abuse had not been escalated, the lack of overall analysis of accidents and incidents meant there was potential for missed opportunities to ensure risks of abuse were identified and addressed. Additionally, feedback from staff suggested inconsistency in which senior staff members they could raise concerns with. This too increased the risk of concerns not being raised.

However, records showed staff had received safeguarding training, and their feedback demonstrated a sound knowledge on how to recognise abuse. Relevant policies were in place to support people, and staff, to report concerns.

People were observed to be comfortable in the presence of staff and were able to request support, showing a degree of trust between people and staff. Relatives fed back no concerns about their loved one’s safety but felt able to raise concerns with management. One relative told us, “I feel [relative] is happy.”

The provider worked with the local authority to investigate allegations of abuse and ensure people’s safety and dignity were promoted.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). The provider managed DoLS effectively, ensuring people were safely supported in line with the principles of the MCA.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We found some care plans contained excessive information which was not always current or relevant. For example, updates from 2021 were still included in some people’s care plans. This reduced clarity for staff supporting people and increased the risk of care being provided inappropriately. We fed this back, and leaders assured us out of date information would be archived.

However, overall people’s risks were identified and assessed. Appropriate guidance was in place to ensure staff supported people who communicated signs of distress safely, including potential triggers and guidance from relevant professionals. The provider was committed to minimising the use of restrictive interventions. Evidence of positive risk taking was found, such as supporting people to independently access the community.

Staff were knowledgeable on how to support people who communicated signs of distress, and the different de-escalation techniques which worked well for people. Staff told us, “You have to read the care plans when you first start, it is very helpful.”

Relatives felt people’s risks were managed safely. One told us, ““I am pleased with the support [person] is getting.” And “The staff are decent people. Staff keep track of [person’s] behaviours.”

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

During our inspection we found the physical environment was not maintained effectively to meet the needs of people using the service. Many areas needed re-decoration, fixtures and fittings were worn or in need of replacement and deep cleaning required throughout the building. The provider assured us that some of these areas would be addressed. There were strong malodours present throughout the building, including the smell of cigarette smoke. The provider told us that some people needed prompting to ensure they smoked outside.

Mould was present within the laundry room. This not only indicated poor IPC standards but increased the risk of infections which can be caused by mould, particularly in vulnerable people. Furthermore, mould can have an impact on the structural integrity of a building. This placed people at risk of harm. We raised this with the provider, who acted promptly and provided assurance that professional services to address mould would be sourced.

Flooring and carpets were not all adequately maintained. We found some lifting of flooring in bedrooms and corridors, and carpets on stairways were frayed and worn, posing trip hazards for those mobilising around the home and preventing effective cleaning. The provider took some immediate action to secure some lifted flooring.

Fire safety checks were completed regularly, however failed to ensure action was taken where risk was identified. For example, mechanisms to ensure automatic closing of doors in the event of a fire were not all in working order according to the provider’s checks. Multiple doors had failed over several weeks, and during our inspection we observed 4 doors propped open with items such as tables and boxes. This was a risk in the event of a fire, as doors would not fully close to slow the spread of a fire. We shared this information with the local fire and rescue team, who were working with the provider to ensure adequate fire safety systems were in place.

The provider did not always make sure there were enough staff to meet people’s needs. We received some feedback that staffing levels were not always sufficient to support people to access the community where they could not do this independently. This meant some people did not have the same opportunities for meaningful activities, or to develop independence. One relative felt that recent staff changes had led to a loss in familiarity, and knowledge on their loved ones needs.

However, staffing levels were informed by people’s dependency needs. This was reviewed regularly. During our inspection there were enough staff on shift, and staff were observed to work together to ensure people had positive interactions and their emotional needs as well as physical support needs were met. Communal areas were constantly supervised.

Staff had received training relevant to their role, including learning disability and autism training, and training on mental health conditions. Staff confirmed they received a suitable induction including shadowing experienced staff prior to working independently. Staff received ongoing support through supervision and team meetings.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The premises and equipment were not clean. During our inspection, strong malodours of stale cigarette smoke and continence related odours were present throughout the building. Staff did not consistently respond in a timely manner to continence-related incidents, or food spillages, which impacted the cleanliness and dignity of people’s environment. Some bedrooms were observed to be cluttered, with visibly dirty bedding, fixtures and fittings. Carpets within the hallways and stairs were embedded with stains and debris, which required deep cleaning.

The kitchen floor was visibly unclean at the time of inspection. It was a concrete surface that required regular stripping and repainting to maintain hygiene standards. However, during our visit, we observed accumulations of dirt and food debris, indicating that cleaning had not been effectively implemented. Furthermore, a staff member was observed preparing food in the area. This increased the risk of bacteria spreading, placing people at risk of infection. The provider took action to clean and strip the floor following our inspection.

The laundry area was visibly unclean at the time of inspection. We found dust, debris and staining on the floor and equipment, including the washing machine. People’s clothing and items such as personal, protective equipment (PPE) was stored in this area, increasing the risk of contamination. Open top bins were used to dispose of items at high risk of infection, such as bags for soiled clothing. This increased the risk of airborne bacteria.

The provider took action to increase cleaning during, and after our inspection.

Systems to monitor infection, prevention and control (IPC) were not effective. Cleaning schedules did not adequately demonstrate that sufficient cleaning had been done on a daily basis, and there was no evidence of manager review. The cleaning schedules only stated that ‘all rooms cleaning done’ with no breakdown of what specifically had been cleaned, including high touch points, communal areas and soft furnishings. Furthermore, the cleaning schedules had gaps, including the whole month of August. Only 1 IPC audit was provided, which had been completed in January 2025. This meant we could not be assured oversight of IPC within the service was consistently or adequately implemented.

The provider responded following our inspection and confirmed increased checks would be carried out.

The provider did not always make sure that medicines and treatments were managed safely and met people’s needs, capacities and preferences. During our inspection we found 1 missing protocol for an ‘as required’ medicine to manage a person’s behaviour. This meant there was no guidance to support staff in when to administer this medicine, and other techniques to use to prevent using the medicine unnecessarily. The manager assured us this would be put in place as a priority. However, staff could explain the signs and symptoms which indicated the person may need this medicine, and techniques to de-escalate.

In addition, when carrying out a stock check of medicines we found 1 tablet which could not be accounted for. Staff and leaders explained a staff member had not signed for the administration and agreed to investigate.

However, we found no evidence that medicines to manage behaviours were over-used. Staff understood the principles of STOMP (Stopping Over Medication of People with a Learning Disability and/or Autism) and worked well with relevant professionals to ensure people’s medicines remained suitable and effective. Where people had their medicines covertly, such as in food or drink, appropriate consultations were had with the GP and pharmacy to ensure this was safe and appropriate.

Whilst medicines were stored, ordered and disposed of safely, further improvements were required to ensure the safe management of medicines.