Victoria House (Wallasey)

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Overall, the service managed the control and prevention of infection well. People were involved in managing risks relating to infection and hygiene. However, we found improvements were needed to ensure processes were fully robust to fully mitigate the risk of infection spread.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We spoke to 4 people who used the service and a relative, all were happy with the cleanliness of the home, comments included, ‘I can’t find fault’ and ‘I think they are clean’, all agreed staff wore PPE when necessary.

Overall, Victoria House was mostly clean throughout, some areas of improvement were required, however, these were being addressed by the provider. People appeared happy and comfortable in their surroundings. Since the recent IPC inspection undertaken by the local authority, the home has made improvements, such as the removal of damaged mattresses and chairs. Ample PPE stock was available for staff to use. Numerous taps were tested throughout Victoria House as it had been picked up by the local authority that there was poor water flow. All had adequate water pressure, facilitating hand hygiene. Posters documenting hand hygiene procedures were laminated and seen around the home. The laundry room was well organised, and people’s clothes were kept separate in order to prevent cross contamination. The kitchen was clean, and the contents of the fridge were appropriately dated. There were some areas where improvement was needed, such as chipped paint on the walls, damaged chairs in the garden room and communal bathrooms requiring further work. However, following on from the visit an improvement plan was received which documented areas of improvement, some already completed since our visit, such as removal of damaged chairs from use. Other areas of improvement have been scheduled to be complete in the coming weeks and months, for example the provider has agreed to review all bathrooms on the first floor and implement new bathrooms.

People who were at risk of infection had detailed risk assessments in place, which were reviewed regularly. IPC training had been completed by staff, the frequency aligned with best practice guidance, however, did not align with the providers IPC policy, this was raised with the manager who was going to address this. Some shortfalls were noted in record keeping, such as fridge and freezer temperature check documents not documenting the temperature range required and water flush documents not documenting the length of time for water flushes. This was fed back to the manager to ensure robust documentation and assurances were gained that changes would be implemented. We received intelligence from the local authority about 3 recent infection outbreaks at the home. We were not fully assured learning from the infection outbreaks was completed in a timely manner. Lessons learnt and actions taken were documented, however this only took place a number of weeks after the event. Although an action plan was submitted to CQC detailing areas for improvement, reflection and learning from events in a timely manner is imperative to ensure the safety of people using the service and decrease the risk of similar events happening. Audits around hand hygiene were not in place, therefore, we were not assured processes were robust. They have since been implemented along with uniform and PPE spot checks.

We spoke with 7 staff members including the manager, care staff, domestic staff, kitchen porter and laundry staff. Staff all agreed they had received training in infection control and PPE was always available when required. They were able to discuss how to prevent the spread of infections and what to do in the event of an infection outbreak. The manager assured us of action taken following the recent IPC inspection completed by the local authority IPC team and discussed the system in place for managing infection outbreaks.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.