Victoria Hall

Updated 16 November 2021

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 Care Act 2014.

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 two inspectors and an 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 Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

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 received feedback from the local authority who was working with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with five people who used the service about their experience of the care provided. We spoke with six members of staff including the provider, registered manager, senior care workers, and care workers.

We reviewed a range of records. This included two people’s care records, and medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We spoke with eleven family members on the telephone. We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.

Updated 16 November 2021

About the service

Victoria Hall is a residential care home providing personal care to 34 people aged 65 and over at the time of the inspection. The service can support up to 37 people in one adapted building.

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

The registered manager was working on making some improvements in the service in regard to safety and records.

We have recommended the provider consider the current guidance on legionella testing in care homes and ensure their policy reflects the guidance provided.

People told us they felt safe. Staff had assessed people's needs and completed risk assessments. People received their medicines safely although some omissions were to be addressed within these records.

Some relative's told us they were not kept up to date about their family’s needs and felt some improvements were needed in the provider’s communication The registered manager assured us action will be taken to address this issue.

Staff received an induction when starting at the service. Regular training, specific to their role, was delivered and refreshed when needed. Staff received supervision and felt supported by the management team.

People said staff were very caring and kind and treated them well. They told us staff maintained their privacy and provided the care they wanted. Staff spoke to people politely and with respect.

Staff had access to sufficient personal protective equipment and used it appropriately. Visitors underwent COVID-19 checks to minimise the risk of spreading of infection.

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 supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

Since the last inspection there has been a change to the provider's registration from a partnership to a limited company. This is the first inspection under their new registration.

The last rating for the service under the previous legal entity was good, (published on 22 June 2018).

Why we inspected

The inspection was prompted in part due to concerns received about a range of issues affecting the safety of people using the service. A decision was made for us to inspect and examine those risks.

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.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.