Archived: Victoria Hall

Updated 21 June 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

We visited the service on 30 April 2018 and the inspection was unannounced. We returned on the 01 May 2018 to complete the inspection. On the first day the inspection team consisted of two inspectors. There was also an expert by experience. An expert by experience is a person who has personal experience of using this type of service. On the second day one inspector completed the inspection.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and any improvements they plan to make. We reviewed information we held about the service, including safeguarding concerns shared with us from the local authority, previous inspection reports and notifications of significant events the provider sent to us. Notifications are events that the provider is required by law to inform us of.

Due to the nature of people's complex needs, we were not able to ask everyone direct questions. We spent time observing people in areas throughout the home to see interactions between people and staff. We observed people as they engaged with their day-to-day tasks, the care they experienced, including the breakfast and lunchtime meal, medicines administration and activities.

We spoke with six people who lived in the service and with three relatives. We spoke with the registered manager and assistant manager. We also spoke with three members of care staff, one activity co-ordinator and the chef.

We looked at the care plans and associated records for eight people, including medicine records. We reviewed other records, including the provider's internal checks and audits, staff training records, staff rotas, accidents and incidents, menu’s, relative questionnaires, and health and safety checks. Records for three staff were reviewed, which included checks on newly appointed staff and staff supervision records.

Updated 21 June 2018

This inspection took place on 30 April 2018 and was unannounced. We returned on the 01 May 2018 to complete the inspection. The management team was given notice of the second date, as we needed to spend specific time with them to discuss aspects of the inspection and to gather further information.

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

Victoria Hall is registered to accommodate 37 people in one adapted building. There were 20 people living in the service at the time of our inspection visit.

There was a registered manager in post. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated regulations.

At the last inspection on 11 and 13 July 2017 the service was rated 'Inadequate.' The report was published in October 2017. At that inspection we identified five regulatory breaches’ of the Health and Social Care Act 2008 (Regulated Activities) 2014. This was due to the registered manager not fully assessing the risk to the health and safety of people using the service. The registered manager was not able to demonstrate that they had sufficient numbers of staffing at all times to ensure people's physical and social needs were adequately met. People were not being adequately supported to have enough to eat and drink and there was poor monitoring of this. The registered manager was unable to demonstrate through her records how they provided individualised care based on the accurate assessment of people's needs. Systems and processes were not sufficiently robust and were not identifying areas requiring improvement.

We also found the service was in breach of one regulation of the Care Quality Commission (Registration) Regulations 2009. This was due to the service failing to notify us of significant incidents in a timely way.

Since our last inspection, we have continued to engage with the registered manager. We required the registered manager to complete an action plan to show what they would do and by when to improve the key questions is the service safe, effective, caring, responsive and well-led to at least good.

At this inspection in April and May 2018, we confirmed that the registered manager and provider had taken sufficient action to address previous concerns and comply with required standards. As a result, at this inspection we found significant improvements had been made and maintained, resulting in the overall rating of the service being changed to, ‘Good’.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

At this inspection for the key question is the service ‘well led’ we have rated it as ‘Requires Improvement’. We found although there were significant improvements in the care planning, time was still needed to ensure they were accurate and fully completed. The provider agreed with our findings and gave a target of May 2018 for completion.

Although at this inspection quality checks had been completed to ensure people benefited from the service being able to quickly put problems right and to innovate so that people consistently received safe care, the previous inspections published in June 2015, September 2016 and November 2017 had identified variable quality and compliance issues. That in some cases the "good" practice had not been sustained over time as a result of gaps in quality monitoring and good governance. Therefore further time and work was needed on behalf of the provider to ensure that "good" practice found at Victoria Hall at this inspection would be sustained through robust and continuous quality monitoring and support.

Staff had received training of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS). This was also covered as part of their dementia training. Our observations confirmed staff promoted choice and acted in accordance with people's wishes. However, not all staff demonstrated a clear knowledge of the MCA and DoLS in our discussions with them. We fed back to the registered manager that staff would benefit from further training. The registered manager gave reassurances staff would be given additional training specifically on the MCA and DoLS by September 2018. The registered manager also gave MCA information cards for all staff to carry on them, to refresh their knowledge, during our visit.

There were systems, processes and practices to safeguard people from situations in which they may experience abuse. Risks to people’s safety had been assessed, monitored and managed so they were supported to stay safe while their freedom was respected. In addition, the necessary provision had been made to ensure that medicines were managed safely. Suitable arrangements had been made to ensure that sufficient numbers of suitable staff were deployed in the service to support people to stay safe and meet their needs. Background checks had been completed before care staff had been appointed. People were protected by the prevention and control of infection and lessons had been learnt when things had gone wrong.

Suitable arrangements had been made to obtain consent to care and treatment in line with legislation and guidance. Care staff had been supported to deliver care in line with current best practice guidance. People enjoyed their meals and were supported to eat and drink enough to maintain a balanced diet. In addition, people had been enabled to receive coordinated and person-centred care when they used or moved between different services. As part of this people had been supported to live healthier lives by having suitable access to healthcare services so that they received on-going healthcare support. Furthermore, people had benefited from the accommodation being adapted, designed and decorated in a way that met their needs and expectations.

People were treated with kindness, respect and compassion and they were given emotional support when needed. They were also supported to express their views and be actively involved in making decisions about their care as far as possible. Confidential information was kept private.

People received personalised care that was responsive to their needs. Care staff had promoted positive outcomes for people who lived with dementia including occasions on which they became distressed. People’s concerns and complaints were listened and responded to in order to improve the quality of care. In addition, suitable provision had been made to support people at the end of their life to have a comfortable, dignified and pain-free death.

There was a positive culture in the service that was open, inclusive and focused upon achieving good outcomes for people. People benefited from there being a management framework to ensure that staff understood their responsibilities so that risks and regulatory requirements were met. The views of people who lived in the service, relatives and staff had been gathered and acted on to shape any improvements that were made. Good team work was promoted and staff were supported to speak out if they had any concerns about people not being treated in the right way. In addition, the management team worked in partnership with other agencies to support the development of joined-up care.