North Downs Villa

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• 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

We assessed all 8 quality statements from this key question. Based on the findings of this assessment, our rating for this key question has improved to good. We found the provider had met some of the breaches we found at the last inspection, including staff training and safeguarding service users from abuse and improper treatment and the home environment. However, we found the provider continued to be in breach of providing safe care in relation to managing risks to people. We also found the provider needed to make improvements to its medicines management. The registered manager shared any new learning and improvements with the staff team. At the time of our inspection people were in the process of transitioning to new services. The provider followed safe hygiene practices to protect people from the risk and spread of infection.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had been in special measures since the last inspection. People told us their experience of care and support had improved during this period, due to the improvements made at the service.

At our last inspection the provider was rated inadequate by the Care Quality Commission (CQC) and placed into provider concerns by the local authority. The registered manager contracted consultants who advised the service about immediate and essential improvements. The registered manager shared this learning with the staff team.

The provider developed an action plan to meet the breaches identified by the CQC during at the last inspection and worked with the local authority’s quality team to reduce risks.

At the time of our inspection people were in the process of transitioning to new services. Whilst care records had been provided for new providers, we found they had not always been updated to show how the heightened anxiety people were experiencing, due to planned moves. should be supported.

The service worked with other providers and health and social care professionals to support people to transition to new services.

The registered manager shared care records including assessments and care plans with social workers to enable them to identify appropriate placements for people.

The service provided prospective providers with care records and supported people to visit potential services.

People told us they felt safe.

At our last inspection we found the provider failed to adequately protect people from the risk of abuse. This was because the provider converted a building in the garden of the property into a residence for an individual who was neither a resident nor a member of staff. This was done without local authority planning permission and without any risk assessments in place to protect potentially vulnerable people living in the service from abuse. This was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Safeguarding service users from abuse and improper treatment. At this inspection the registered manager feedback to us that the individual who lived in the structure in the garden was no longer residing there. However, another individual had moved into the structure for use as a dwelling contrary to local authority planning permission. We will continue to liaise with the local authority about this concern.

We observed that people were kept safe from harm and abuse.

The provider had put in place measures to protect people from abuse. These included risk assessments, background checks and a strengthen of the separation of the environments to ensure that anyone inhabiting the structure in the garden could not access the care home. This meant the service was no longer in breach of regulation 13.

People told us they felt safe.

The registered manager told us that he had reviewed and updated people’s risk assessments since the last inspection. Staff told us they understood people’s risks and had read their risk assessments.

We observed that people were not always involved in the planning of their care. This meant they were not involved in aspects of managing their care and were not given the opportunity to provide guidance for staff in preventing certain risks.

At our last inspection we found a hole in the carpet on the stairs which could cause a fall and window without a restrictor which caused a risk of a person falling from height. This was a breach of Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014. At this inspection we found that appropriate repairs had been made and the provider was no longer in breach of this part of regulation 12. Since the last inspection we the provider had developed new risk assessments. However, we noted these did not demonstrate people’s involvement, evidence updates following review or provide clear guidance for staff on the actions they should take to avoid and prevent certain risks. We also noted inaccuracies such as wrong people’s names and genders within risk assessments. The failure to assess and mitigate risks to people was a continuing breach of Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People spoke positively about the improvements made to the home environment since the last inspection. People had no concerns about the safety and quality of the environment. One person told us, “I noticed they have been improving the house.”

At our last inspection we found chipped, scratched and stained walls in the lounge and dining room, broken tiles on the wall in the bathroom, tired décor and worn furnishing in communal areas and debris in the garden. This was a breach of Regulation 15 (Premises and equipment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection, the décor and furnishings had been improved and there were no rubbish piles in the garden. Consequently, the provider was no longer in breach of regulation 15. The registered manager explained to us the environmental auditing process they followed to ensure the care home remained safe.

We found the environment was safe for people to live in.

At our last inspection we found a hole in the carpet on the stairs which could cause a fall and window without a restrictor which caused a risk of a person falling from height. This was a breach of Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014. At this inspection we found that appropriate repairs had been made and the provider was no longer in breach of this part of regulation 12.

People received their care and support from staff who were recruited through robust recruitment processes.

Staff received the supervision and training they required to meet people’s needs safely and effectively.

We observed there were enough staff employed to support people.

At our last inspection we found people were supported by staff who were not adequately supervised. This was a breach of regulation 18 of the Health and Social Care Act 2014. staffing. At this inspection we found that staff received regular supervision and the provider was no longer in breach of regulation 18. At our last inspection we found that staff had not received the training they required to keep people and themselves safe during behavioural support incidents. The failure to ensure staff had the skills to support people safely was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment. At this inspection we found that staff had received training in supporting people when they displayed signs of distress. This meant the provider was no longer in breach of this part of regulation 12.

People thought the environment of the care home was clean and told us that staff used personal protective equipment appropriately.

The registered manager and staff received training in infection prevention and control. This included food safety and the use and safe storage of potentially hazardous cleaning materials.

We observed staff following safe hygiene practices such as wearing appropriate Personal Protective Equipment (PPE)

The provider followed safe hygiene practices to protect people from the risk and spread of infection. This included the appropriate use of personal protective equipment, the availability of hand sanitizers and food safety practices to prevent cross contamination.

People were supported to take their medicines, when required. Some people were able to administer their own medicines but occasionally needed some prompting from staff to do this, which was provided. People told us they received the medicines they were prescribed and consented to their administration.

We noted for one person there was no guidance on their records about when to administer their ‘when required’ medicine. We discussed this with the registered manager who told us the person was responsible for taking their own medicines but sometimes may ask for help with this. The registered manager told us they would update the person’s records after our visit to make sure staff had the relevant information needed to support the person safely and effectively with this medicine, when this support was required.

Improvements had been made to medicines management and administration since the last inspection. Medicines stocks, balances and records showed people received the medicines prescribed to them. The provider’s policies for medicines and homely medicines had been updated in line with current practice and shared with all the staff team. Staff practice in relation to record keeping had improved. Regular checks were undertaken of medicines to make sure these were managed safely.