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 requires improvement. At this assessment the rating has remained 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 governance at the service.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had focussed on improving the care home’s environment. Staff spoke positively about the improvements that had been made and about wanting to give good care to people living there.

Further improvements were required to ensure people could more easily access opportunities for activities, interests and hobbies. Staff told us they had plans to make improvements in this area.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. However, not all staff who contributed to aspects of leadership had clearly defined roles.

Staff spoke highly of the registered manager, saying they were kind and supportive. Staff told us they worked well as a team and communicated well together in handover meetings. However, where care staff were tasked with completing work that contributed towards the leadership and development of the service, it was not clear how these had been defined or how they were accountable. This meant aspects of the provider’s service development and leadership were not always transparent.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

All staff we spoke with told us they felt able to raise any concerns with the registered manager and other leaders at the service. The provider had a whistleblowing policy in place to support staff in this process.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Whilst some audits and governance checks were completed, these did not provide a full overview of the quality and safety of services. For example, there were no checks completed to ensure the basic safety of premises such as window restrictors and the safety of heavy items of furniture.

Systems and processes to ensure the registered manager reviewed accident and incident forms to check all appropriate actions had been taken, including assessment for safeguarding referrals and notifications to the Care Quality Commission, were not operated effectively. Notifications are changes, events or incidents that providers must tell us about. They are important as they help to show the provider is working in a transparent and open way. Other checks on the quality and safety of services were also not consistently reviewed and checked by appropriate leaders. For example, there were no management checks recorded on cleaning schedules to ensure these had been completed as expected and there were no audits on staff recruitment files to ensure they met the standards expected in the provider’s own policy.

Whilst an action plan was in place to manage some improvements in the service, ongoing audits did not always identify when actions had been completed. For example, when mattresses had been ordered when audits found they needed replacement.

Records of people’s care and incident reports were not always written with enough details to fully understand what had occurred. For example, staff had sometimes used subjective terms rather than describing what had occurred. This meant there was a risk some records could be inaccurate or incomplete.

Systems and processes to ensure risks relating to staff deployment, clarity of staff roles and who staff were accountable to, were not always operated effectively. Not all staff roles were clearly shown on staff rotas. This meant records of what roles staff were doing when, were not always accurate. Staff rotas showed some staff regularly worked long hours over consecutive dates. There were no recorded risk assessments to show how any risks associated with fatigue and competence from working long hours over consecutive days had been considered.

Some staff completed additional roles in addition to their care role. These were not always clearly defined, nor did they always report directly to the registered manager. This meant there was a risk of confusion about who was responsible for completing tasks and a lack of accountability regarding these roles.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People were happy with how they were supported when they needed care from other partner agencies. One person told us, “The staff support me with my hospital appointments.” Another person told us the GP visited them at home.

The provider was working with the local authority on an action plan to make improvements to the service. We observed staff liaised with other partner agencies to ensure a person was supported with the care they needed following discharge from hospital. The service collaborated and worked with other agencies to help people receive the care they needed.

The provider had made some improvements, however more improvements were needed to show they were focused on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Whilst improvements had been made to the premises and the cleanliness of the home, other improvements in governance systems had still to be implemented and fully embedded. The provider’s systems did not yet fully ensure opportunities for continuous improvement and learning were embedded and effective.