North Downs Villa

What inspectors found

From the Care Quality Commission's assessment published 10 October 2024 (assessment visit 23 May 2024). Quoted under the Open Government Licence.

1. Safe

   GGood Good

   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.

2. Effective

   GGood Good

   We assessed all 6 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 the breach of regulation we found at the last inspection around treating people with dignity and respect.

   People's dependency needs were assessed which staff used to develop care plans. Staff worked together to deliver and meet people’s needs and wishes in line with legislation and current evidence-based good practice and standards. People were supported to stay healthy and well. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. The care and support people received was routinely monitored.

3. Caring

   GGood Good

   We assessed all 6 quality statements from this key question. Based on the findings of this assessment, our rating for this key question has remained good.

   Staff knew people well and understood their individual preferences. People were treated with dignity and respect. Progress had been made on supporting people’s independence since the last inspection. Staff were aware of the signs that indicated people’s needs were increasing, however some aspects of care planning needed updating in relation to promoting mental health.

4. Responsive

   GGood Good

   We assessed all 7 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 the breach of regulation we found at the last inspection around person centred care.

   People were supported to engage in activities of daily living. The provider made information available to people in a way that was accessible to them. The registered manager ensured that care records and staff were available to support people’s transitions into new services. People told us that staff treated them fairly and spent their time equally between them to meet their needs.

5. Well-led

   GGood Good

   We assessed all 7 quality statements from this key question. Based on the findings of this assessment, our rating for this key question has improved to good.

   Not enough improvement had been made in relation the breach of good governance we found at the last inspection. we found the provider continued to be in breach of this regulation.

   Staff told us that the registered manager had an open-door policy and was supportive. The registered manager arranged team meetings and invited staff to share their views about improvements to the service. Staff told us they believed significant improvements had been made at the service since our last inspection.