We inspected Victoria House on 29, 30 April and 11 May 2015. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.
At the last comprehensive inspection in November 2014 we found that there were multiple breaches of the regulations relating to care. In light of this we varied the provider’s conditions of registration to prevent people with certain types of conditions being admitted to Victoria House.
We revisited the home in December 2014 and found significant improvements had been made. We did, however find that the home was in breach of regulations relating to: assessing and monitoring the quality of service provision; respecting and involving service users; and records.
At this inspection we reviewed the action the provider had taken to address the above breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We found that the provider and manager had continued to oversee the way the care and treatment was delivered and the overall operation of the home; had improved the way staff worked to support people to be as independent as possible; had improved record keeping practices and these had led to the home meeting the above regulations.
Victoria House is registered to provide nursing and residential care for 68 people and the service operates across three distinct units. The home caters for people with a physical disability and people with dementia some of whom may need nursing care. At the time of the inspection 44 people lived at the home.
In December 2014 the registered manager resigned. 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 this inspection we found a new manager was in post and they had applied to become the registered manager but noted they commenced working at the home mid-April 2015.
During the inspection we found that the new manager had commenced a range of processes designed to monitor and assess the ongoing performance of the home, such as audits. We found that this review had led to actions plans being developed. We saw that the processes had led the manager to quickly gain in-depth knowledge of the home and areas for improvement.
We found, as the manager had, that closer scrutiny needed to be given to ensuring sufficient staff were on duty with the skills, experience and competency to meet people’s needs. The provider had converted the unit, Regent House to meet the needs of older people. This meant the 44 people were accommodated in the physical disability unit; middle floor nursing unit, top floor nursing unit and the Regent House unit.
Although the provider completed a needs analysis and this led to 1 nurse and eight staff being on duty during the day and 1 nurse and 5 care staff overnight. No consideration was given to the design and layout of the building. This layout of the building meant, particularly overnight, one staff member was left to cover whole floors and they did not have swift access to support. We observed that even with one member of staff acting as a float it took 40 minutes for the lone worker to get the support they needed to complete positional changes. Also some of the people displayed marked behaviours that challenge and this had not been factored in to how many staff were needed to ensure people remained safe in these units. We found that the provider had not risk assessed the impact that the building and lone working would have upon the delivery of safe care.
We saw there were systems and processes in place to protect people from the risk of harm. However, these needed to be improved as staff were not reporting incidents to senior staff.
We found that in between December 2014 and the new manager starting much of the useful dementia friendly items had been removed but not replaced with anything meaningful. Also the activities coordinators had left and were in the process of being replaced. This change meant that people were not engaged in meaningful activity and occupation throughout the day and we heard from visitors this had been usual for the home since February 2015. The manager was aware of this issue. They discussed the plans for improving this aspect of people’s lives. We found that the manager had obtained a range of items people could use to entertain themselves; they had created new spaces in the home for people to go; they had employed a new activity coordinator and they were in the process of creating a new café.
Staff had a greater understanding of the requirements of the Mental Capacity Act 2005 and had appropriately requested Deprivation of Liberty Safeguard (DoLS) authorisations. Staff had been working hard to ensure capacity assessments were completed in line with the Mental Capacity Act 2005 code of practice. They and the manager recognised that they were still developing the skills needed to always complete these accurately and they needed more space on the sections relating to people’s ability to take on board information to write their analysis.
We found that the manager had worked closely with staff to ensure they provided care and treatment that was effective. We saw that all interactions between staff and the people who used the service were person-centred and supportive. We found that this had led to improvements in individual’s presentation and we were able to hold full conversations with people who used the service. This change meant we could talk to people about their care.
We found that care records now reflected the treatment people received and staff routinely ensured, when necessary individuals were referred to external health care professionals.
Staff took action to monitor people’s weight and ensured they were provided with sufficient food and fluid. The cook designed menus that were nutritious and offered a range of alternatives including fortified for people who were at risk of losing weight.
We found that medication practices had improved and staff were administering prescribed medicines safely.
We heard how the manager was in the process of reviewing people’s needs to ensure the home could meet their needs. Where this was not the case the manager had taken action to ensure the person’s needs could either be met or they moved to more suitable accommodation.
We found that staff were appropriately recruited and had received a wide range of training including condition specific training such as courses related to supporting people who were living with dementia.
People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff or relatives to hospital appointments.
People told us they were now confident that should they have a complaint this would be fully investigated by the manager and resolved to their satisfaction.
The manager and staff had reviewed and updated all of the records maintained at the home such as care records, audits, policies and training information.
We found that the building was very clean and was being maintained. We found that all relevant infection control procedures were followed by the staff at the home.
When we concluded our inspection the provider had resolved the breaches of regulations identified at the last inspection. We found that action was needed to address aspects of one of the regulated activities regulations 2014, of the Health and Social Care Act 2008, which you can see at the back of the full version of this report.