Victoria House

Updated 7 March 2023

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 was carried out by 1 inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Victoria House 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 is a care home with 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 the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 4 people, 3 relatives and a visiting vicar. We spoke with 5 staff, including the regional manager, registered manager, nursing, care and domiciliary staff. We reviewed 3 care records, a range of medicines records and a range of records relating to the management of the service. 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.

Updated 7 March 2023

About the service

Victoria House is a care home providing personal and nursing care to up to 30 older people, some of whom were living with dementia. At the time of our inspection there were 27 people using the service.

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

The provider had improvement plans in place. However, service design and decoration was in need of refurbishment in some areas. Signage was not in place to assist people living with dementia to orientate themselves around the home. Some people's rooms were not personalised, and some people were required to share rooms. People were offered choice of meals and people told us they enjoyed their meals. At our previous inspection we recommended the provider introduced staff training in line with the Care Certificate standards: at this inspection this was not embedded into practice. Staff had received some training to support people in line with their needs, however some training regarding clinical skills, staff understanding their role and professional development was not provided. Staff told us they were supported in their roles and received regular supervisions. New staff received an induction and shadowing opportunities.

Peoples needs and choices were assessed and documented in person centred care plans, this included people's communication and end of life care needs. We observed staff offering choice to people during our inspection and people told us staff respected their privacy and dignity. The staff team worked closely with external agencies to ensure people's healthcare needs were met. 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.

Systems and processes were in place to protect people from the risk of abuse and avoidable harm. Risks to people were assessed and people and their relatives told us they felt safe in the home. Environmental and equipment checks were in place. However, we found hoist slings were not labelled, with people sharing slings. The registered manager provided assurances following the inspection that this concern was now rectified, to promote safety and reduce the likelihood of cross contamination. People were supported by enough staff who were recruited safely. People and their relatives told us there were enough staff and staff were kind. Medicines were safely managed. The service was clean, and systems were in place to control and prevent the spread of infections. There were no recent accidents or incidents. Systems were in place to monitor and review incidents which may occur.

Staff knew people well. A ‘resident of the day’ system was ongoing to ensure people were offered the opportunity to provide feedback and auditing of care records was undertaken. The registered manager understood their roles and responsibilities in relation to duty of candour and reported incidents to CQC and safeguarding where required. Staff understood their roles and responsibilities. People, relatives and staff told us leadership was good and there was an open and honest culture in the home. The registered manager received support from a regional management team. People were supported to maintain relationships and to receive visitors to maintain their religious and cultural needs. Regular audits were conducted, and overarching governance was in place. Improvement plans were in place and the service was currently conducting refurbishments of the environment, however not all areas identified during the inspection had been considered.

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 requires improvement (published 1 July 2021).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 requires improvement to good based on the findings of this inspection.

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.

Recommendations

We have made a recommendation the provider reviews staff training to incorporate the Care Certificate. The Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. It is made up of the 15 minimum standards that should form part of a robust induction programme

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.