The Villas Care Homes Ltd

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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

This service scored 46 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Whilst a range of policies and procedures were in place to support the service delivery, these were not always followed. For example, an IPC policy highlighted the governance systems required to oversee IPC within the service, but these were not in place. Failure to follow policies and embed safe practices placed people at risk of receiving care that was not in line with expected standards.

However, staff demonstrated a commitment to providing quality person centred care. One staff told us, “The residents are the best thing about working here, your heart connects with them. I am here to provide the best care I can, for them.” Another told us, “You get close to the residents here, staff are very co-operative, and everyone guides you and helps you, I like that kind of environment and think it is good to work here.”

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

At the time of our inspection, there was no registered manager in post. While the deputy manager was overseeing day-to-day running of the service, the absence of a registered manager contributed to inconsistent oversight and a lack of strategic leadership. Additionally, there was a lack of clarity around roles and responsibilities, particularly in relation to who was accountable for ensuring that identified actions were followed through. For example, the deputy manager told us they reported concerns to the provider, but it was not always clear what had been addressed, by whom, or within what timeframe. As a result, risk or quality concerns risked being overlooked and action delayed.

The provider told us they were in the process of recruiting for a registered manager.

People did not always feel they could speak up and that their voice would be heard. Whilst relevant policies were in place to support staff in raising concerns, some staff told us they felt more comfortable speaking up to certain individuals than others. We were assured that the recruitment of a registered manager, and clear roles and responsibility would support a safe environment for staff to speak up.

Relatives confirmed they knew how to raise concerns and felt they would be listened to.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Policies were in place to support the diverse workforce. Staff confirmed they had not experienced discrimination in regard to any protected characteristic whilst working at the service. One staff member told us, “Everyone is treated fairly in my opinion.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Some relevant audits were in place to oversee risk within the service. For example, tissue viability audits to monitor skin integrity. However, the provider did not always consistently act on findings when audits identified areas of risk. For example, a mattress audit repeatedly flagged a failing mattress over several months, yet no remedial steps were taken to replace or repair it. Lack of timely or effective action left people at risk of receiving poor care.

Following our inspection, we met with the provider who suggested the leadership team increased their daily checks to ensure better day to day oversight of risk and quality.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff and leaders did not always collaborate with partner agencies for improvement. Some external agency audits and inspections had identified areas of risk, but the provider had not taken action to address these areas at the time of our inspection. This included fire safety concerns, and IPC.

However, people’s care records showed clear collaborative working with a range of health and social care professionals. This included mental health teams, GP’s and social workers.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider’s service improvement plan did not contain all identified actions through audits and therefore could not demonstrate how improvements were being made. Furthermore, some actions added in 2022 were marked as ‘ongoing’ with a lack of evidence to show progress or resolution. Without a comprehensive improvement plan and timely actions, the provider lacked a clear framework to ensure accountability and monitor progress over time. This increased the risk safety and/or quality of care being compromised.