Victoria House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At the lasted rated inspection this key question was rated as good. At this inspection the rating has remained good. This meant overall people were safe and protected from avoidable harm. We found the two units damaged by the fire had undergone a full refurbishment. The provider had employed a new external company to complete the fire risk assessment and had followed their action plan. A new fire system had been installed, smoke detectors were being fitted in line with the Fire Authority guidance and the provider was in the process of ensuring new fire doors were fitted across the home and the compartmentalisation of stairways was completed. The provider had a programme in place, which would ensure all the works were completed. The registered manager had ensured whilst the ongoing works were being completed robust fire risk measures were in place. The maintenance staff completed regular checks of the building and made sure all the staff completed simulated fire drills on a regular basis. The infection control team had visited and identified areas for improvement. The registered manager had ensured the issues were addressed. People told us they felt safe. Staff understood safeguarding procedures and referrals were made as needed. Risks were assessed and action taken to mitigate any risks. Medicine management was effective. Staff who administered medicines had the appropriate training. The registered manager ensured staff were trained to use equipment and understand how to check items were fit for purpose. Recruitment practices were meeting requirements. There were enough staff to deliver the care people needed. The registered manager actively promoted using information from lessons learnt to continuously enhance the service.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People felt the service responded to and met their needs. People on the younger adults’ unit told us staff listened to their views about how well their support was being provided and involved in how it was delivered. The staff and management team would make changes and check with people if these were effective. One person said, “The staff are great. If I want something done different, we talk about it and see how to do this.” People and relatives did not specifically discuss whether there was a learning culture but most did tell us they were included in discussions, they were able to raise concerns and these were resolved. A relative said, "The staff have full knowledge of [person's name] needs and requirements. They ask us what we think; and if they see things need doing, staff get them done."

The registered manager constantly critically reviewed the operation of the service and used all information to assist them to understand themes, reasons for the events and lessons, which could be learned. For example, they identified audits staff completed needed to have a review mechanism in to support individuals remain alert to issues. This assisted staff understood the need to critically assess their units and quickly let the management team know if items such as fridges need to be replaced. Staff found the registered manager encouraged them to be open and transparent with people. They discussed how they prioritised their work to ensure people were safe and well-cared for first. A staff member said, " I love working for here. Everybody really wants the best for the people and we are encouraged to share our ideas about how to make the home the best it can be."

Systems were in place to identify any lessons learnt and take appropriate action. The registered manager continually looked at how to enhance the service and involved all the staff and people in thinking about creative ways to ensure the service delivered optimum care and support. There were multiple examples of significant improvements to the well-being of people. For instance, staff had provided signs and records translated in to different languages, which had readily assisted individuals find things and understand what the expectations were around communal living. The registered manager ensured lessons learnt were shared with staff via team meetings and supervision. The registered manager could readily identify where gaps existed and acted swiftly to address them. They effectively monitored the quality and safety of the service and ensured people experienced positive outcomes from the support they received. Action plans were used to monitor whether the changes implemented had improved the service. They used all feedback to assist them improve the quality of care.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People across all the units reported they were very happy with the service and felt safe. A person said, "They keep me right and I’m very happy here."

The registered manager discussed how measures were in place to ensure staff understood when to make safeguarding referrals and how they worked as a team to ensure people were protected from harm. Staff told us they received regular safeguarding training and understood what processes to follow to make an alert. Staff made safeguarding referrals when needed. A staff member said, "I always make sure everyone is kept safe and will raise any concerns with the management team or if needed contact the safeguarding team."

People and relatives told us happy with the service. A relative said, "The standard of care my father-in-law receives is excellent." We observed staff worked with people in a sensitive, caring and considerate manner. They encouraged people to be as independent as possible and really encouraged them to reach their full potential. All interactions were conducted in a positive manner.

The provider had safeguarding systems in place. When appropriate staff had made safeguarding alerts to the local authority safeguarding team and sent us the required notifications and reports. Staff said they had training and a good understanding of what to do to make sure people were protected from harm or abuse.

People told us they had no concerns. A person said, “We {person and staff} look at what things are risky for me and worked together to put plans in place to reduce them.” A relative said, “[Person’s name] physical and psychological needs are met in every way, and changes are made as and when their needs change.”

Staff understood when people required support to reduce the risk of avoidable harm. The risk assessments in place were very detailed and effectively assisted staff to safely mitigate risks. A staff member said, “People can have a range of needs which can, at times, lead to them being at risk, for example, of injury. We work with each person to find out how best to manage any risk and record this in care plans.”

Our observations raised no concerns about how the service managed risks to people.

Risk assessments were in place and assisted staff readily identify how to mitigate risks. The management team consistently worked with staff to review people’s needs, identify any changes to their health and well-being and produce additional risk assessments when needed. The care and support risk assessments were very detailed, proportionate and effectively assisted staff to safely mitigate risks.

People told us staff had the skills and knowledge to carry out their role effectively and use any equipment safely. Relatives felt the standard of upkeep of the building could be improved but did not impact the care provided. A relative said, “The old-style building may appear off-putting but it cannot be stated how little this matters.” A person said, “[Registered manager’s name] makes sure the home is kept tip-top.”

Maintenance staff understood the requirements of their role and completed all the necessary checks. They were ensuring staff regularly completed simulated fire drills. Staff had received training around adopting safe working practices and following best practices guidance. They felt safe working at the service and had access to all the appropriate equipment they needed.

We observed the parts of building damaged in the fire have been completely refurbished. A new fire system has been installed and measures to finish compartmentalisation on the stairwells underway. Smoke detectors, fire stopping blocks, and new doors are in the progress of being fitted throughout the home. Progress is phased and broken into floor, with the works on ground floor now complete. Where areas had been redecorated this had been done to a good standard. We saw plans were in place to complete works to the same standard of decoration throughout the whole building. The registered manager had created a space in the chapel for charging the mobility scooters and electric wheelchairs.

Environmental risks were assessed and addressed. Since the fire at the home last year work was being undertaken to complete all of the requirements outlined in the Fire Authority notice. Worked was still to be completed across phase 2 and 3 of the plan to bring the service fully in line with the fire safety legislation. The provider and registered manager had ensured the highest risks to people had been addressed. The provider had policies in place for the maintaining health and safety within the service. The management team made sure staff had received training to support people who used equipment, such as mobility aides. This included how it was cleaned, calibrated and safe. They understood what risk assessments were needed to make sure staff followed health and safety guidance.

People and relatives found there were always enough staff on duty. A person said, "There are always plenty of staff around and come straight away if I need a hand." A relative said, “I visit at different time and never have any issues finding staff, as they are always nearby.”

Staff reported there were enough care workers to meet people's needs and they worked together effectively to provide safe care that meets people’s individual needs. The registered manager carefully considered dependency levels across each unit and what would be safe staffing levels if there was an emergency. A staff member said, “We work well as a team and never feel there isn’t enough staff.”

People appeared happy with the service. We observed there were enough staff on duty to meet people’s care and support needs.

Robust and safe recruitment practices were in place, and these made sure staff were suitably experienced, competent and able to carry out their role. Recruitment, disciplinary and capability processes were fair and were reviewed to ensure there was no disadvantage based on any specific protected equality characteristic. We saw evidence confirming when there had been changes to individual’s care and support needs the management team made sure additional staff were available if needed. The staffing levels and skill mix ensured people received consistently safe, good quality care that meets their needs. Staff receive the support and training they needed to deliver safe care. This included supervision, appraisal and support to develop, and improve services and where needed, professional revalidation. Staff received training around all aspects of care including condition specific training and the required courses around working with people who lived with a learning disability and Autistic people.

Overall people found staff followed expected infection control practices. A person said, "Although it’s an old building staff always make sure it’s clean." A relative had raised concerns about the cleanliness of the service, which the manager had addressed and ensured staff completed regular checks to make sure people’s rooms remained tidy.

The infection control team had visited and identified areas for improvement, which included the need for new fridges, microwaves, flooring, washable furniture and equipment such as bath chairs needed to be robustly. The registered manager had ensured the identified actions were being addressed. They had immediately purchased new fridges and microwaves, and a refurbishment programme was underway which would address issues. They had also ensured the cleaning schedule was reviewed. Staff confirmed they received training on infection control procedures. They had all the equipment they needed to reduce the risk of spreading infections and understood the need to keep these clean.

We observed refurbishment works were underway and many parts of the service had been redecorated. New items such as fridges and microwaves had been purchased. The service looked clean and tidy.

The provider had systems in place to mitigate the risks of people and staff from catching and spreading infections. We saw evidence to confirm staff had received infection prevention and control training and their practices were regularly checked. Following the report from the infection control the registered manager had identified a gap in how the information from infection control audits were completed and shared with them. They had worked with staff to make sure they critically reviewed their units and raised any identified issues in a timely manner.

People and relatives found medicines were managed in a safe manner. A person said, “The staff are great and always make sure I get my meds when I need them.”

People’s medicines were managed in a safe manner. We found staff understood their role in ensuring medicine was safely administered. Staff were trained in medicines management and processes were in place to assess whether staff were competent to administer people’s medicines.

Staff followed best practice when administering medicines and followed STOMP guidance, which meant people’s behaviour was not inappropriately controlled by medicines. Assessments and care plans were produced; these detailed what medication people received and why.