Archived: Grove Villa Care

Updated 2 July 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection site visit took place on 16 January 2018 and was unannounced. The inspection was carried out by two inspectors.

We used information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make. We looked at the previous inspection reports and any notifications received by the Care Quality Commission. A notification is information about important events, which the provider is required to tell us about by law.

We spoke with the registered manager, the deputy manager, a senior and two members of care staff. We looked at six people’s care plans and the associated risk assessments and guidance. We looked at a range of other records including four staff recruitment files, the staff induction records, training and supervision schedules, staff rotas and quality assurance surveys and audits.

During the inspection we spent time with and spoke with the people living at the service. We observed how people were supported and the activities they were engaged in. Some people were unable to tell us about their experiences of care. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

After the inspection we spoke with the local authority commissioning team about our concerns.

Updated 2 July 2021

This inspection took place on 15 January 2018 and was unannounced.

Grove Villa Care is a care home registered to provide accommodation and personal care for up to 16 people. 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. People using the service had a range of physical and learning disabilities. Some people were living with autism and some required support with behaviours that challenged.

The service had a registered manager in post. A registered manager is a person who is registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations, about how the service is run.

We last inspected Grove Villa Care on 20 April 2017, we found significant shortfalls and the service was rated inadequate and placed into special measures. The provider and registered manager had failed to notify CQC of notifiable events in a timely manner. Risks relating to people's care and support were not always adequately assessed or mitigated. Medicines were not managed safely. The provider had not ensured that staff had all the training they required to meet people's needs, support them consistently and keep them safe. The provider and registered manager had failed to enable and support people to communicate their preferences. People did not always receive care and support in the way they preferred and were not enabled to understand their care and support options. People did not always receive person-centred care. Staff and the registered manager were not fully aware of their individual responsibilities to identify and report abuse when providing care and treatment. People were not fully protected from abuse and the registered manager had not followed the correct procedures to make sure people were as safe as possible. The provider and registered manager had failed to establish and operate systems to assess, monitor and improve the quality of the services provided and reduce risks to people. The provider and registered manager had failed to make suitable arrangements to respect and involve service users and had failed to maintain accurate and complete records.

We took enforcement action and issued a warning notice relating to ‘Safe Care and Treatment.’ We placed a positive condition on the provider’s registration, asking them to send us monthly updates regarding the service. We required the provider to make improvements and the service was placed in special measures. Services that are in special measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. At this inspection we found that improvements had been made in some areas, however there were still serious concerns regarding the provider’s oversight and overall management of the service and some continued breaches of the regulations.

The service was not fully working towards Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; the policies and systems in the service did not always support this practice. Some people were not allowed to access their kitchen, even though they wanted to, as staff described it as ‘unsafe.’ No risk assessment had been completed regarding the risk of people using the kitchen and no plans were in place to increase people’s independence and skills.

At our last inspection, risks relating to people’s care and support had not always been assessed and mitigated. At this inspection the registered manager and deputy manager had begun to re-write people’s care plans. Nine of 16 had been completed. The new care plans contained more detail regarding how to give people appropriate support, such as how to recognise and respond if they experienced a seizure or displayed behaviour that challenged. However, there was still a lack of essential guidance for staff if people choked. The care plans that had not been updated still did not contain information regarding people’s seizures and when staff should seek medical assistance. When incidents occurred the deputy manager now completed an overview of incidents to look for patterns and trends and ways of reducing the chance of them happening again.

Staff did not always treat people in a respectful manner. They had written that people were ‘hoarders’ and ‘messy eaters’ and had given no consideration to how people may have felt to be described as such. A staff member had headphones in throughout the inspection and ignored people when they spoke to them.

A communication board had been introduced which enabled people to make choices between different things such as different foods and activities by using pictures. The registered manager and deputy manager had chosen not to implement a recommendation from a speech and language therapist regarding a visual timetable for a person and told us they were using the communication board instead. The communication board did not provide the same support as a visual timetable.

Staff had not received training in best practice for supporting people with learning disabilities. The registered manager lacked the knowledge and understanding regarding supporting people with learning disabilities. Although some care plans had been re-written since our last inspection, people’s needs had not been assessed in line with best practice as a result.

People were going out more regularly since our last inspection and the deputy manager regularly monitored when people were going out and how often. The registered manager completed checks on the service, but had not identified the issues we highlighted at this inspection. The provider lacked oversight of the service. They did not complete any formal checks and the registered manager had not received regular supervision. We requested information to be sent after the inspection, and this was not received in a timely manner. Although some action had been taken since our last inspection both the provider and registered manager had failed to acknowledge the severity of the issues identified and the breaches had not been met fully. We had not been notified of safeguarding incidents that occurred within the service, as required by law and staff had not been recruited safely.

People and their relatives were asked their views on the service annually, but had not been asked formally, since our last inspection. The service had received some support from the local authority safeguarding and commissioning teams since our last inspection. They were working with the registered manager and staff to encourage improvements. There were enough staff to keep people safe. Medicines were now managed safely and people received them as and when required. People received support to manage their health care needs, and saw a doctor when they became unwell. People were supported to eat and drink safely. The service was not currently supporting anyone at the end of their life

Some areas of the service had been re-decorated since our last inspection and people had been involved in choosing the colours of the walls. The service was clean and people were protected from the spread of infection.

The registered manager told us there had been no complaints since our last inspection. The registered manager had applied for Deprivation of Liberty Safeguards when people’s liberty was restricted.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.