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 requires improvement. At this assessment the rating has remained 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.

This service scored 59 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Accidents and incidents were recorded however, these sometimes lacked detail and were not always used to inform further organisational actions and learning. Whilst some completed incident forms were used to help inform other health professionals involved in people’s care, others had not always resulted in a review of relevant care plans or risk assessments. Some incident forms had not always identified additional reasonable steps that could have been taken to help reduce the risks involved. This meant opportunities to improve safety had not always been taken.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

People told us they felt safe living at their home and raised no concerns with how they were cared for. Staff had been trained in safeguarding to help them identify potential signs of when a person may be experiencing abusive behaviour. However, not all staff demonstrated a competent knowledge of this when they spoke with us. Records of potential safeguarding incidents had not always been shared with the local authority with no decision recorded as to why a safeguarding referral was not needed. This meant not all steps to help safeguard people from abuse had been taken.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider had a system to track and monitor when people required a Deprivation of Liberty Safeguard to be in place. The provider followed the principles of the MCA when people needed to make decisions.

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.

Actions to help manage risks to people were not always included in their care plans and risk assessments. This included where additional cleaning routines were completed to help ensure people’s environment remained hygienic. Additionally, incidents had not always led to actions on how to manage new risks when they emerged. For example, where people had smoked in areas other than the designed safe smoking area. This meant people were at risk of receiving inconsistent care to help them stay safe.

Staff were knowledgeable on people’s communication needs and any risks associated with eating and drinking.

Information on people’s care needs and what was important to them was available to accompany them should they require a hospital admission. This helped to ensure any risks to people could be managed more safely in emergency situations.

The provider did not always detect and control potential risks in the care environment. The home did always provide a therapeutic environment where people could partake in activities that benefitted them.

Improvements had been made to the care home environment, and it was clean, well-maintained and well-decorated throughout.

Checks were made to ensure some risks in the environment were reduced. However, some further checks were needed to ensure other areas of the premises remained safe. For example, there were no regular checks that window restrictors remained in working order and wardrobes remained secured to walls. We found 3 wardrobes were not secured on our assessment and one uncovered radiator. These present risks of heavy furniture toppling over and risks from hot surfaces. The registered manager told us they would take immediate action on these issues.

People told us they would like more activities within the care home environment. One person said, “I would like the home to get some games to play like Monopoly and playing cards. The home does not have an activity coordinator; it would be good if they had one.” Another person told us, “I have never seen any activities in the home taking place.” We saw people enjoyed musical activities and records showed people were supported out into the community. However, some further improvements were needed to ensure people experienced a consistent therapeutic home environment that supported them to engage in activities that were meaningful to them.

The provider did not always manage recruitment of new staff to the standards expected or ensure staff roles were clearly defined.

People told us staff were available to help them when needed. One person said, “I find the staff kind and caring and when I do ask for support the staff come quickly.” We observed staff were available to meet people’s needs in a timely manner and planned to support a person to access the community.

When new staff were appointed, not all recruitment checks had been completed to the standards set out in the provider’s recruitment policy. Nor had the required checks to explain any gaps in new staff members’ employment histories been completed. This meant the provider’s checks on new staff members had not always been completed to the required standards.

Not all staff roles were clearly defined or reflected accurately on staff rotas. When care staff worked on shift but had additional roles, such as maintenance, it was not always clear when time was allocated for these additional roles to be completed without impacting on care hours.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People were happy with how their home was cleaned and maintained. One person told us, “The home is well decorated, furnished and the communal areas are kept clean.”

We found improvements had been made to how risks from infection were managed. Improvements had been made to the environment, and this was now clean and tidy.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People told us they were happy with how staff managed their medicines. One person said, “I am supported with my medication and happy with the care.” Another person told us, “I am provided with support with my medication 4 times per day.” However, we found 2 topical skin creams had not been stored in line with good practice. We informed the registered manager who told us they would take action to store these appropriately.