Victoria Manor

Updated 7 February 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 was planned to check 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.

This inspection took place on 8 November 2017 and was unannounced. The inspection team consisted of two inspectors.

We reviewed the information we held about the service including contact made by members of the public (this was both before and after our inspection visit). We looked at information received from agencies involved in people’s care including the local authority commissioners who funded care for some people at the home. They confirmed information the service had shared with us about reportable incidents at the home. We looked at the Healthwatch report which had been completed following their visit to the home on 31 October 2017. This was a positive visit. We analysed information on statutory notifications received from the provider. A statutory notification is information about important events which the provider is required to send us by law. These can include safeguarding referrals, notifications of deaths, accidents and serious injuries. We considered this information when planning our inspection of the home.

We used information the provider sent us in the Provider Information Return (PIR). This is information we require the providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We looked at three care plans and viewed other care documentation such as people’s weight charts, medicine records, food and fluid records. We looked at accidents and incident records, health and safety records, the complaints file, safeguarding referral records and quality monitoring checks carried out by the provider. We attended a handover meeting with staff at the beginning of the morning shift with both day and night staff.

We spoke with three people who were able to speak with us and observed how people were cared for on each floor. We spoke with three visitors to the home including a healthcare professional. We spoke with the registered manager, four care staff, the housekeeper, the maintenance person, the cook and the area director who was visiting the home.

Updated 7 February 2018

The last inspection took place on 1 September 2015 when this service was rated as ‘good’. This inspection took place on 8 November 2017 and was unannounced. We found the service continued to be good in four of the key questions. Some improvements were identified in relation to the key question of Safe. The provider had recognised there had been a decline in some standards at the home following our last inspection and had acted upon these to ensure the home continually improved.

Victoria Manor 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 care home provides personal care, including for those living with dementia, and accommodates up to 30 people across two floors. There were 26 people living in the home at the time of our inspection.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had been in post since June 2017 and was registered with us in August 2017.

People told us they felt safe living at Victoria Manor and there were systems and processes to protect people from the risk of harm. Staff knew how to manage risks associated with people’s care and to report any concerns to the registered manager. There were enough staff available to support people’s needs but we received varying views of the effectiveness of staff, partly due to the number of agency staff used in the home.

There was a procedure to manage people’s medicines but this was not consistently followed to ensure medicines were managed safely.

The environment had been adapted to take into account people’s physical needs and to support people’s dementia. There was a process to undertake safety checks of the environment and equipment although we identified some hot water pipework that had not been covered to minimise the risk of burns to people. The home was clean and staff understood what was expected of them to maintain good infection control practice within the home.

Staff received training in areas considered essential to meet people’s needs safely and consistently, and there were enough suitably trained staff to meet people’s personal care needs.

New staff received an induction to the home that helped them to understand the individual needs of the people who lived there.

Staff had a working knowledge of the Mental Capacity Act and understood the need to ensure people consented to care before this was provided. Where restrictions on people’s liberty had been identified, Deprivation of Liberty Safeguard (DoLS) applications had been made to the local authority.

Staff were caring and considerate in their approach to people and did not rush people when supporting them. They understood the need to respect people’s privacy and dignity and to give people choices about how they spent their day. People had access to some social activities of their choosing and were also able to participate in group activities. We saw positive engagement between people and staff. The activity co-ordinator (referred to as wellbeing co-ordinator) post was vacant at the time of our visit.

People were provided with a choice of meals and these looked hot and appetising. Snacks and drinks were provided throughout the day to maintain people’s nutritional needs.

People accessed healthcare professionals when needed. A GP visited the home each week and people were also supported to attend regular health checks to maintain their physical and mental health.

Staff were positive about working at the home and felt supported by the management team. There were quality monitoring systems and processes to ensure the home ran effectively. People and staff had opportunities to share their opinions and views of the home to help drive improvement. A programme of audit checks ensured the service worked in accordance with the provider’s policies and procedures.

There was a complaints procedure on display to inform people and visitors on how to raise a complaint. Records were kept of complaints received and we saw action had been taken to respond to them.