Background to this inspection
Updated
25 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.
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
This inspection was undertaken by 1 inspector.
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 the information we held about the service, including the statutory notifications we had received from the provider. Statutory notifications are reports about changes, events or incidents the provider is legally obliged to send to us. We contacted the local authority commissioning and safeguarding teams, the local NHS IPC team, fire service and Healthwatch to request feedback. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.
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 3 people who used the service and 4 relatives about their experience of the care provided. We spoke with 3 members of staff including the registered manager, service provider manager and a senior carer. We also requested feedback from 9 members of staff by email and received 4 replies. We reviewed a range of records. This included care records for 6 people including medicines records. We looked at the recruitment records for 3 staff and a variety of records relating to the management of the service, including policies and procedures. We also received feedback from 2 health and social care professionals who visited the service.
Following the inspection site visits we requested additional information by email and continued to seek clarification from the provider to validate the evidence we found. We also sought advice from pharmacy inspector colleagues to discuss the inspection evidence linked to the provider’s medicine policy.
Updated
25 January 2023
About the service
Victoria House is a residential care home converted from three terraced houses. Residential care is provided for people who have a learning disability, physical disability or those with autism. The service provides personal care and support to up to 9 people. At the time of the inspection there were 9 people living at the service.
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
People’s experience of using this service and what we found
Right Support
The service was registered with CQC prior to the publication of the Right support, right care, right culture guidance. The size of the service was larger than current best practice guidance. However, the layout of the building meant there were separate communal areas people could access to decide who they wanted to socialise with.
Records did not always demonstrate medicines were managed safely. The policies and procedures in place lacked detailed guidance of how staff should provide support. The infection, prevention and control [IPC] policy and procedure did not provide detailed information in relation to safe practices to help prevent the spread of infections. The safeguarding policy did not evidence the provider understood their responsibilities in relation to safeguarding procedures.
People were supported to personalise their bedrooms to reflect their taste and preferences and their opinions were sought to ensure people were included in decisions about their care. Risk assessments were completed to assess known risks people were exposed to and people were encouraged to be as independent as possible.
Right Care
There were sufficient numbers of staff to meet people's needs. Staff knew people well and knew the most effective ways to communicate with people to overcome any communication barriers. Information was available to people in alternative formats to support people's communication needs if this was necessary.
Staff treated people with care and kindness and supported people to take part in a range of activities appropriate to them. Assessments of people's needs had been completed and care plans had been developed to meet people’s needs.
Right Culture
The culture at the service was positive. The management team led by example and staff worked in ways which were person-centred to the needs of individuals. People and relatives gave positive feedback about the caring attitudes of staff.
People were supported to take part in activities of their choosing and had opportunities to socialise and go on holiday if they wanted to. Feedback from people confirmed they were happy living at the service and felt safe.
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 this practice.
Recruitment records did not demonstrate safe recruitment procedures were always followed. Staff worked in an open and transparent way. However, records were not available to demonstrate staff were meeting the requirements of the duty of candour regulation. We have made a recommendation about this.
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 20 September 2019).
Why we inspected
We received concerns in relation to the management of the service and support provided to people. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
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.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. The provider started to take action to address the issues identified during our inspection.
You can see what action we have asked the provider to take at the end of this full report.
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.
Enforcement and Recommendations
We have identified breaches in relation to safeguarding people from the risk of abuse and good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.