Victory Socialcare Enterprise

Updated 3 May 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 one inspector.

Service and service type

Victory Socialcare Enterprise 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. Victory Socialcare Enterprise 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 the provider was the registered manager.

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. 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 1 person who used the service 3 relatives about their experience of the care provided. We spoke with 7 members of staff including the provider, director, deputy manager, senior care workers and care workers.

We reviewed a range of records. This included 3 people’s care records and multiple medication records. We looked at 4 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 3 May 2023

About the service

Victory Social Care Enterprise is a residential care service providing accommodation to a maximum of 12 people, some of whom are living with dementia. At the time of this inspection there were 10 people using the service.

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

At the time of the inspection, the location did not care or support for anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.

Right Care:

The provider had not ensured all staff were suitably trained or supported to perform their roles. Some staff required refresher training to ensure they had the knowledge and skills to safely meet people’s needs. Staff did not receive regular supervision; however, staff felt the registered manager was supportive and approachable.

Staff did not always follow risk assessments effectively.

Medicines were managed safely however, guidance for staff relating to medicines which were prescribed on an ‘as and when required’ basis (PRN) needed more detail.

There were enough staff. Staff were recruited safely and received an induction to ensure they had the skills and knowledge to undertake their role.

Right Support:

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.

Care plans were being updated to ensure people received person centred care.

The service gave people care and support in a safe, clean, well-furnished environment. People were supported to make decisions following best practice in decision making and staff communicated with people in ways that met their needs.

Right Culture:

The ethos, values, attitudes and behaviours of management and care staff were working towards ensuring people using services led confident, inclusive, and empowered lives. The provider worked closely with the local authority to create an action plan to improve the service and to embed these changes within practice however, further improvements were needed to ensure changes were fully embedded in practice. We have made a recommendation about this.

People and those important to them were involved in planning their care and staff evaluated the quality of care supported to people, involving the person, their families and other professionals as appropriate.

Systems were in place for communicating with people, their relatives and staff to ensure they were fully involved. Feedback from people and their relatives was positive. Relatives told us they were happy with the service and care given.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update and update

The last rating for this service was requires improvement (published 07 May 2019)

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations.

The last rating for this service was requires improvement (published 07 May 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.

You can see what action we have asked the provider to take at the end of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

Enforcement and Recommendations

We have identified breaches in relation to assessing risk, staff training, staff supervision and poor-quality assurance systems.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.