Archived: Moor Villa Farm

Moor Villa Farm is a residential care home which was providing care to three people at the time of the inspection. The service specialises in providing recovery and rehabilitation for up to five younger adults with complex mental health difficulties.

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

People were not receiving a service that provided them with safe, effective care. Risks associated with people's behaviours were not managed safely. Risks within the environment were not effectively mitigated which meant people were placed at risk of significant harm.

Medicines were not always administered as prescribed and infection control procedures did not support people to remain safe during the pandemic. Recruitment practices were robust.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support. The provider was not following proactive best practice models to reduce the need for restrictive interventions.

We found systems and processes used to ensure the service was running safely were not effective. We observed a lack of leadership, direction and oversight. The registered manager did not oversee the day to day running of the service and told us they rarely visited the service. An acting manager supported staff and people, but they lacked understanding of the importance of maintaining a safe environment for people.

The provider’s quality assurance systems had failed to identify significant risks to people. The inspection team identified a number of serious risks within the environment. The provider and registered manager were asked to address these immediately. We revisited the service to check on improvements that the provider told us they had made. Sufficient action had not been taken to ensure people using the service were safe. The provider then made the decision to close the service.

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

Rating at last inspection

This service was registered with us on 25 September 2020and this is the first inspection.

Why we inspected

The information CQC received about the incident indicated concerns about the management of ligature risks. This inspection examined 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.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this full report.

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

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to the safety of people and management oversight at this inspection.

We recognised that the provider had failed to ensure risks to people were effectively, assessed, managed and mitigated. This was a breach of regulation and we issued a notice of decision to impose conditions upon the providers registration.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.