Glebe Villa

Updated 10 January 2023

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 Health and Social Care Act 2008.

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

The inspection was carried out by one inspector.

Service and service type

Glebe Villa is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Glebe Villa is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with five people who used the service about their experience of the care provided and spent time with others observing interactions with staff. We spoke with four members of staff, the registered manager, the operations manager and the provider. We spoke with three relatives and contacted four health and social care professionals about their experience of the service . We reviewed a range of records. This included three people's care records, daily records and medication records.

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.

We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed. We continued to seek clarification from the provider to validate evidence found. We looked at training data, care plans and quality assurance records.

Updated 10 January 2023

About the service

Glebe Villa is a residential care home providing accommodation and personal care for up to seven people with a learning disability. At the time of this inspection there were six people in residence.

People’s experience of using this service and what we found

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Improvements had been made to enable people to have maximum choice and control of their lives and how staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

At the last inspection the service was not always able to demonstrate how they were meeting some of the underpinning principles of Right support, Right care, Right culture. This had improved since the last inspection. Staff had received some training since the last inspection including the use of restraint and safeguarding. Further training was needed such as supporting people with learning disabilities and dementia.

Improvements had been made to the records kept in the home including incidents, accidents and the use of restraint. The use of restraint had significantly reduced since the last inspection with staff using a more person-centred approach.

People had access to health care professionals. Improvements had been made to the records relating to healthcare with everyone now having their own individual health record. This meant staff could easily monitor and review each person and people’s confidentiality was maintained.

Right Care

People and their relatives said they were happy with the care and support. People had personalised their bedrooms. People were now supported to go shopping, to the local hairdressers and other places of interest. People told us they were planning holidays for next year.

People were still not being protected by the provider's recruitment process because staff had not had the right checks completed in respect of a Disclosure and Barring Check. Assurances were provided that this would be completed immediately.

Right culture

Improvements had been made since the last inspection.

People were now being supported in a way that enabled them to have choice and control in their daily lives. The routine of the home seen at the last inspection that was potentially having a negative impact on people was being addressed. Activities people wanted to take part in, and the structure of the day was being reviewed. House meetings had been reintroduced so people could have influence on how they received support and the running of the home.

People's aspirations and goals were being explored to ensure they were living the life they wanted to. This work was still ongoing and needed to be embedded and sustained.

Improvements had been made to ensure the provider had oversight of the service with improved checks being put in place. This work was ongoing with a newly appointed operations manager.

Systems had been reintroduced to monitor and make improvements to the service. These needed to be fully embedded and sustained. Areas identified at the last inspection had been addressed in respect of safety, such as radiator covers and door guards.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 23 August 2022)

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found some improvements had been made and the provider was no longer in breach of regulations in respect of good governance, safeguarding, treating people with dignity and respect, staffing numbers and safe care and treatment. The provider remains in breach of regulations in relation to safe recruitment and staff training.

This service has been in Special Measures since 23 August 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements and the warning notices that were served in respect of dignity and respect and good governance. This report only covers our findings in relation to the key questions safe, effective, caring and well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

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.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Glebe Villa on our website at www.cqc.org.uk.

Enforcement and Recommendations

The provider remains in breach of regulations found at the last inspection. These relate to the recruitment of staff, staff training and the provider's governance arrangements.

We have recommended the registered manager and the provider improve their knowledge and understanding of regulatory requirements to help them have a better understanding of managing and operating a care home and help drive improvements.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.