Background to this inspection
Updated
29 December 2022
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 team was made up of 2 inspectors.
Service and service type
Victoria House Residential Care Home 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. Victoria House Residential Care Home 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 who work with the service. We used all this information to plan our inspection.
During the inspection
We conducted 2 site visits as part of this inspection, on 21 and 23 November 2022.
We spoke with the director of the company registered to operate the care home (‘the owner’) who was also the registered manager; the deputy manager and 2 members of the care team. We also spoke with 5 people and 2 relatives about their experience of the care provided.
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 reviewed a range of written records including 4 people’s care files, 2 staff recruitment files and information relating to the auditing and monitoring of service provision.
After the site visits we reviewed further information we had requested from the provider.
Updated
29 December 2022
About the service
Victoria House is a residential care home providing personal and nursing care to up to 20 people. The service provides support to older people, people living with dementia and people with physical disabilities. At the time of our inspection there were 11 people using the service.
People’s experience of using this service and what we found
People’s medicines were not always managed safely. There were a number of issues including; the lack of protocols in place for people who received as required medicines and a lack of running totals of some controlled drugs, these are medicines which require specialist storage by law. Storage of some medicines were not in line with legislation.
Risks to people’s safety was not always clearly recorded. There was conflicting information in people’s records about their care needs as changes to their needs occurred. There was a lack of processes to show clear learning from events.
Quality assurance processes were not always robust. This had resulted in some of the findings above. Some audit findings had not been addressed, such as areas of concern highlighted in environmental audits.
More positively, staff were knowledgeable about people’s needs. There was enough staff to support people as the registered manager and their staff team worked extra shifts to ensure people were well supported.
Staff recruitment processes were safe.
People and relatives liked the staff who supported them and felt they were caring and approachable. During our inspection we observed a number of positive interactions between staff, the people they supported and their relatives.
There were processes in place to ensure people were protected from the risks of abuse. People, relatives and staff had confidence the registered manager would deal with any concerns appropriately.
People were protected from the risk of infection as staff followed good infection prevention and control practices to reduce the risks.
People were able to have visitors and relatives told us they felt welcomed into the service.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
The registered manager worked in an open way promoting choice and person-centred care for people. They led by example. People were encouraged to take part in resident meetings and give their opinion of the service via questionnaires.
Staff had received appropriate training to guide them in their roles and were supported with supervision and staff meetings.
The registered manager and their staff team worked with external health professionals to ensure people’s needs were supported.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 16 January 2020).
Why we inspected
This inspection was prompted by a review of the information we held about this service. We highlighted concerns around the management of risk and governance following our own monitoring processes. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
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.
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 Good to Requires Improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the Safe 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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Victoria House on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to regulations 12 and 17 of the Health and social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to manage medicines in a safe way and the quality monitoring processes were not robust enough to identify the issues we found in relation to medicines, care plans and the environment at this inspection. Following our inspection, we received information from the provider to show they had addressed the concerns found at inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
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.