Archived: Victoria House

Updated 17 February 2022

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

The inspection team was made up of one inspector, a medicines inspector and an Expert by Experience who had consent to phone and gain feedback on the care provided by the service from people’s relatives. 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 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

The first and second days of the inspection were unannounced.

What we did before the inspection

Before the inspection we reviewed the information we held about the service, including notifications we had received. Notifications are changes, events or incidents the provider is legally required to tell us about within required timescales. We sought feedback from the local authority.

We used this information to plan the inspection. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spent time with and spoke with three people living at the service, three relatives, three agency and two permanent members of staff, the registered manager. We also spoke with four senior managers who supported the inspection on behalf of the provider. To help us assess and understand how people's care needs were being met we reviewed four people's care records. We also reviewed a number of records relating to the running of the service. These included staff recruitment and training records, medicine records and records associated with the provider's quality assurance systems.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with two health care professionals, and representative from Torbay Council's quality assurance and improvement team (QAIT) and three relatives.

Updated 17 February 2022

About the service

Victoria House is a residential care home that provides personal care and support for up to six people with a learning disability, autism or who have complex needs associated with their mental health. At the time of the inspection there were four people living at the service.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, 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 or autistic people.

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

The provider could not show how they met some of the principles of Right support, right care, right culture. This meant we could not be assured that people who used the service were able to live as full a life as possible and achieve the best possible outcomes.

Although people told us they felt safe living at Victoria House, relatives spoken with said they did not have confidence in the service and did not feel their family members were safe or well looked after.

People were not always protected from the risk of avoidable harm. We found where some risks had been identified, sufficient action had not always been taken to mitigate those risks and keep people safe.

People who had behaviours that could challenge themselves or others had proactive plans in place to reduce the need for restrictive practices. However, some staff had limited knowledge of people’s needs or key pieces of information relating to people's care and support. This meant people were not supported to have maximum choice and control of their lives and staff were not supporting people in the least restrictive way possible and in their best interests.

People were not always supported by staff who understood best practice in relation to learning disability and/or autism, as set out in our guidance Right Support, right care, right culture.

There were insufficient numbers of suitably qualified, competent, skilled or experienced staff on duty to meet people’s needs safely.

Some areas of the service were not clean, and we were not assured the service was following safe infection prevention and control procedures.

Governance systems did not ensure people were kept safe and received a high quality of care and support in line with their personal needs.

Following the first day of our inspection the provider advised the Commission, relatives and Torbay and Devon County Council of their intention to close 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 and update

The last rating for this service was Requires improvement (published on 04 February 2021) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made/sustained, and the provider was still in breach of regulations.

Why we inspected

We received concerns in relation to the management of risk, staffing levels, staff training and people’s personal care needs. 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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.

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

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so. We have identified breaches in regulation in relation to safe care and treatment, safeguarding people from abuse, staffing, and governance. Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements. If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We will meet with the provider following this report being published and work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.