Victoria House

Updated 20 January 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.

Inspection team

The inspection team consisted of 2 inspectors and 1 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 House 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 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. 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

During the inspection we spoke with 7 people using the service and 3 relatives to gain feedback on their experience of care provided. We spoke with 14 staff members. This included the registered manager, quality improvement manager, deputy manager, team leaders, care staff, administrator and activity co-ordinator. We looked at 10 people’s care records and 3 staff files in relation to recruitment. We reviewed training and supervision records for all staff. We also looked at a variety of records relating to the management of the service including audits, staff rotas, safeguarding and incidents.

Updated 20 January 2023

About the service

Victoria House is a residential care home providing accommodation and personal care for up to 47 people. The service provides support to older people, people living with dementia and people with a mental health diagnosis. At the time of our inspection there were 33 people using the service.

Victoria House has 6 separate wings, each of which has separate adapted facilities. One of the wings specialises in providing care to people living with dementia and another specialises in providing support for people living with a mental health condition.

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

People were protected from the risk of harm, felt safe, and staff were aware of how to raise any safeguarding concerns. Care and risk support plans set out people’s known risks and provided guidance to ensure staff could provide safe care. Some risk assessments did not contain enough detail, and this was rectified during the inspection. Medicines were managed safely. New staff were safely recruited and there were enough staff to meet people’s needs. The provider was working within current government guidance in relation to infection control and there were no restrictions upon visiting arrangements. Incidents and accidents were acted upon appropriately and lessons were learned when things went wrong.

Some improvements to the décor would be beneficial to support and stimulate people living with dementia, We have made a recommendation about the environment in the effective section of the report., the registered manager began to work on this during the inspection. People were assessed prior to moving into the service and were supported by staff with a good level of knowledge and skills. People received effective support with eating and drinking. People were supported to have control over their lives. Staff worked with other agencies, seeking advice and support when needed. The service made use of adaptive technology to support independence and reduce risk.

Mental capacity assessments were in place for people who lacked or had fluctuating capacity to make specific decisions, but these did not cover all key decisions. Staff knew about the Mental Capacity Act 2005 (MCA) and how to support people to make day to day choices about their care and routines. Staff supported people in the least restrictive way possible and in their best interests however these decisions were not always recorded, this raised the risk of decisions being made which did not always follow the principles of the MCA.

Systems in place to monitor the quality and standards of the service were not always effective. We found inconsistencies in records relating to allergy information, diabetes risk assessments and MCA assessments. There was a positive culture in the service. People said the registered manager was approachable and responsive. Staff received regular supervision and 1 to 1 meetings to support learning and development. The provider had clear policies and procedures in place to support staff. There was an ongoing improvement plan for the service. The provider ensured any lessons learned from incidents was shared across the service and region.

People were treated with respect and their dignity was upheld. People were involved in their care planning. We observed staff interacting with people in a friendly and supportive way. There was a positive approach to the delivery of people's care. Staff understood the people they were supporting and knew them well.

Care plans contained information about people’s preferences and people received care tailored to their needs and wishes. Activities were planned to enable people with a range of communication needs to be involved. There was easy read information available in the service. The provider responded appropriately to complaints and sought out regular feedback from staff, relatives and people using the service.

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 good (published 28 December 2018).

Why we inspected

The inspection was prompted in part due to concerns received about staffing in the service. A decision was made for us to inspect and examine those risks. We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the Safe section of this report.

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 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.