This inspection took place on 19 and 23 March 2018. The inspection was unannounced on the first day. This meant the staff and provider did not know we would be visiting. The second day was announced.Victoria Court is a domiciliary care agency. Victoria Court is a large complex of houses where people can access the domiciliary care agency which is based on site. Not all people living at Victoria court received personal care and we only inspected those people who received a regulated activity. It provides a service to older adults. Not everyone using Victoria Court services receives a regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene, eating and medication. Where they do we also take into account any wider social care provided. At the time of our inspection, 17 people were using the service.
There was no registered manager however; the manager of the service had applied to the Care Quality Commission to become the registered manager and that this was being progressed. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At the last inspection we rated the service overall ‘Good’ however, at this inspection we found that improvements were required and rated the provider ‘Requires improvement’. At the last inspection we found the provider did not always follow The Mental Capacity Act 2005, as capacity assessments and best interest decisions had not been recorded. At this inspection we found some improvements had been made with capacity assessments in place however, not all best interest decisions had been completed, when required. We made a recommendation that the provider research the MCA to ensure best practice is followed.
We found improvements were needed to fully ensure effective systems and processes were in place to monitor and improve the service. Audits did not always identify when actions were required and not always completed in a timely manner. Records were not always robust to show that actions had been completed.
We found risk assessments had not always been followed by staff to ensure people’s safety and avoid potential harm.
Staff did not always receive supervisions and appraisals in line with the provider’s policy however, staff told us they felt supported and were provided with the appropriate training.
Medicines were safely administered most of the time however, medication errors had not always been reported and actions had not been taken to mitigate risks. 'As required' medicines were administered accordingly and protocols were in place for staff to follow.
There were sufficient staffing levels however; some people felt that more staff were required due to waiting times. Recruitment procedures were safe for employed staff however, the relevant checks to ensure agency staff were eligible to work with vulnerable people had not always been completed.
People told us they felt safe and staff had a clear understanding of the procedures relating to safeguarding and whistleblowing. People told us staff were kind and they felt listened to by staff. Staff respected people’s privacy and dignity at all times.
People were supported with their health and nutritional needs and were provided with a range of food and drink.
People were encouraged to remain independent and make choices about their care. Care plans were detailed and included people's preferences and likes and dislikes, which promoted person centred care.
Complaints had been responded to with outcomes recorded. People using the service told us they felt confident to discuss any concerns with the provider. Incidents and accidents that had been reported were monitored and managed effectively.
Surveys were provided to people to gather their views of the service. The provider had a ‘you said, we did’ document which allowed people to see the changes made by the provider.
We identified two breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014, (Good governance) and (Safe care and treatment). You can see what action we told the provider to take at the end of the full version of this report.