Background to this inspection
Updated
20 August 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
Day one of the inspection was carried out by one inspector, an assistant inspector and a specialist advisor who was a nurse, on the 14 June 2021. One inspector returned to the home for a second day on the 15 June 2021. An inspector and an Expert by Experience made calls to relatives and staff from 14 June 2021 to 25 June 2021. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
The Village is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
Day one of the inspection was unannounced.
What we did before inspection
We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection
We spoke with two people who lived at the home about their experience of the care provided. The majority of people living in the home were unable to communicate with us due to their health conditions. We spent time observing people in the communal areas of the home. We saw how they were being cared for and supported by staff and used these observations to help us understand peoples' experience of living at the home. We spoke with six relatives of people living at the home.
We spoke with the nominated individual, the registered manager and the deputy manager. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We also spoke with one nurse, three senior carers, eight care staff, the head chef and a member of the housekeeping staff.
We reviewed a range of records. This included eight people's care records and four people's medication records. We looked at two staff files in relation to recruitment. We also looked at records that related to the management and quality assurance of the service.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at safeguarding and quality assurance records.
Updated
20 August 2021
About the service
The Village is a care home providing personal and nursing care to 33 older people including people living with dementia at the time of the inspection visit. The service can support up to 90 people. The accommodation is provided over two floors each of which has its own communal areas.
People’s experience of using this service and what we found
People’s medication was not appropriately stored in a locked cabinet and medication trolleys were not locked and secure.
We also found the audit analysis completed following an accident or incident could be improved to identify trends and themes to reduce the risk of reoccurrence. In addition, issues we found during the inspection were not identified by the provider’s auditing processes.
We found the provider could make improvements to make the home more dementia friendly to ensure people had a comfortable environment. For example, we found some of the decorations around the home were confusing for people who had dementia.
People or their relatives were not involved in reviews of their care.
Risks to people's health and well-being had been assessed and monitored to ensure they were kept safe.
The provider had safeguarding systems and processes in place to keep people safe. Staff knew the risks to people and followed the assessments to ensure they met people's needs. People felt safe and were supported by staff who knew how to protect them from avoidable harm.
People lived in an environment that was clean and well maintained.
Staff observed and followed infection control procedures in line with national guidance for reducing the spread of Covid-19.
Staff were recruited safely and there were enough staff to meet people's needs. Staff followed the infection control procedures the provider had in place.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People were assessed before they used the service to ensure their needs and preferences could be met. Staff understood the importance of ensuring people's rights were understood and respected.
People and their relatives told us they felt well cared for by staff who treated them with respect and dignity and encouraged them to maintain relationships and keep their independence for as long as possible.
People’s communication needs were assessed and understood by staff. People were provided with information in a format which met their needs.
Staff liaised with other health care professionals to ensure people's safety and meet their health needs.
Staff spoke positively about working for the provider. They felt well supported and that they could talk to the management team at any time, feeling confident any concerns would be acted on promptly. They felt valued and happy in their role.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
This service was registered with us on 13/10/2020 and this is the first inspection.
Why we inspected
The inspection was prompted in part due to concerns received about the management of safeguarding incidents. A decision was made for us to inspect and examine those risks.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.
We have identified a breach in relation to Regulation 12 (safe care and treatment) at this inspection. The provider responded to the concerns on the day of the inspection. Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.