Background to this inspection
Updated
2 October 2020
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.
Inspection team
The inspection was completed by one inspector.
Service and service type
Victoria Court 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.
Notice of inspection
We gave the service 24 hours’ notice of the inspection. This was because the service is small and people are often out and we wanted to be sure there would be people at home to speak with us.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work 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 four members of staff including the registered manager, deputy manager and care workers. We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at a variety of records relating to the management of the service, including policies and procedures.
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 also spoke with one professional who had regular contact with the service.
Updated
2 October 2020
Victoria Court is a nursing home providing nursing care to nine people at the time of the inspection. The service can support up to 16 people. Victoria Court accommodates people across three separate wings, each of which has separate adapted facilities including a kitchen and living area.
People’s experience of using this service and what we found
Whilst people reported feeling safe and cared for in the home, there was not a consistent approach to assessing people’s risks and taking action to reduce these.
People were not always protected from risks relating to the environment where they were at risk of self-harm.
People received their medicines safely from trained staff, however, medicines audits had not always identified where the service had not disposed of medicines where people had left the service.
Quality assurance tools had failed to identify where improvements were required in people’s care and documentation.
We have made a recommendation about people socially isolating in line with government guidance when newly admitted to the home.
Staff were knowledgeable about safeguarding and people felt able to raise concerns.
The home was clean and staff understood their infection control responsibilities.
People told us that staff were responsive to their needs and we received consistently positive feedback about staff and the management team.
People were encouraged to be involved in their care planning and making decisions around their care.
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 requires improvement (published 19 April 2019). 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 or sustained and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.
Why we inspected
This was a planned inspection based on the previous rating.
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 monitor the service and 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 relation to people’s safety and good governance at this inspection.
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
We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.