CQC report explained · a residential care home, run by Surrey Mental Health
North Downs Villa
19 Elmwood Road, Croydon, CR0 2SN
Rated Good: inspectors found the service performing well and meeting their expectations.
What inspectors found, December 2023
North Downs Villa was rated Inadequate and placed in special measures; inspectors found serious safety, leadership and independence concerns.
This was an urgent, unannounced comprehensive inspection on 29 September 2023. Inspectors spoke with people, staff and healthcare professionals. They reviewed care records, staff files, medicines records, policies and quality checks. They also inspected the building and grounds.
The home was not keeping people safe. There were safeguarding risks linked to a separate residence in the grounds, missed notifications to CQC, gaps in staff training and hazards in the building. The home was also restrictive, and people were not given enough support to build everyday living skills and independence.
The overall rating fell from Requires Improvement to Inadequate. Safe and well-led were rated Inadequate. Effective and responsive were rated Requires Improvement. Caring remained Good. The home was placed in special measures, and CQC requested action plans and said it would continue to monitor progress.
Suitable recruitment
The home used applications, interviews, references, identity checks and DBS checks when recruiting staff.
“Staff were recruited through a process involving application, interview and background checks.” from the report
Access to healthcare
People had timely support to attend GP appointments and meet specialist mental health professionals.
“People had timely access to healthcare professionals. For example, staff supported people to attend GP appointments and recorded the outcome of these visits.” from the report
Respectful privacy
Inspectors saw staff knock on bedroom doors and wait for permission before entering. Care records also included personal care preferences.
“We observed staff knocking on people's bedrooms and awaiting their permission before entering.” from the report
Support with communication and relationships
Communication needs were assessed, and staff supported people to maintain contact with relatives when they wished.
“Staff supported people to maintain contact with people who were important to them.” from the report
Safeguarding risks
seriousPart of the grounds had been converted into a residence for someone who was not a resident or staff member. The home had not assessed the risks this created for people, visitors or staff.
“The provider failed to adequately protect people from the risk of abuse.” from the report
Serious incidents not reported
seriousThe provider did not notify CQC about significant events, including safeguarding allegations that had been substantiated by the local authority.
“The provider did not inform CQC when local authority social workers investigated and substantiated abuse allegations.” from the report
Staff training gaps
seriousStaff had not received the training needed to manage behavioural support needs safely. The home also did not provide supervision at the frequency set out in its policy.
“Staff did not have the training they required to always keep people safe.” from the report
Poor environment
needs fixingThe home was worn and not dementia friendly. Inspectors found damaged walls, broken tiles, waste in the garden and uncomfortable furniture, including a chair with a collapsed seat.
“The lounge area of the service was not comfortable or welcoming.” from the report
Restrictions and limited independence
seriousPeople could not use the kitchen or laundry without staff. Staff usually completed cooking, cleaning and laundry instead of teaching people these skills.
“People could not access the kitchen or laundry room because both rooms were locked.” from the report
Weak management oversight
seriousThe home's audits did not identify important problems, and senior staff could not access all requested records when the registered manager left during the inspection.
“The provider's quality assurance processes were inadequate.” from the report
- 01What safeguards and risk assessments are now in place concerning the separate residence in the grounds?
- 02What action has been taken to make sure all safeguarding incidents are reported to CQC without delay?
- 03Have all staff completed behavioural support training, and how often are staff now supervised?
- 04What repairs and changes have been made to the lounge, stairs, garden and dementia-friendly signage?
- 05How are people now being supported to use the kitchen and laundry and develop independent living skills?
This was an urgent, unannounced comprehensive inspection covering all five key questions, including the building, grounds, care records, staff records, medicines and infection control. This explanation was written from the published report of 23 December 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of North Downs Villa
7 rated inspections over 8 years: the service has slipped, from Good to Inadequate.
- December 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- October 2020Requires improvementstayed Requires improvementSafe: Inspected but not ratedEffective: GoodResponsive: Inspected but not ratedWell-led: Requires improvement
- October 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2019Requires improvementstayed Requires improvementEffective: Requires improvementWell-led: Requires improvement
- August 2018Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- December 2011
Registered with the Care Quality Commission on 21 December 2011.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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