Archived: Victoria Court

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.

People’s experience of using this service: At this inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to person-centred care, safe care and treatment and governance.

People told us they felt safe. However, risk assessments did not identify all risks to people and staff, including environmental risks.

Improvements were required to the building to ensure it was suitable for its intended purpose. It did not provide a well-maintained, safe and comfortable home for people. Arrangements for managing people’s medicines were not safe, when people kept their own medicines.

Records did not provide guidance to staff to ensure people received safe, appropriate care and support, including for any therapeutic interventions.

We have made a recommendation best practice guidance is followed about using nationally recognised assessment tools and models of care planning to meet people's needs.

Staffing levels were sufficient but we have made a recommendation that the numbers of staff and staff deployment are kept under review. This to ensure that staff are available to spend time with people and that their needs are met in a person-centred way.

Staff knew about safeguarding procedures. Appropriate checks were carried out before staff began to work with people.

Staff had an understanding and knowledge of people’s care and support needs. They received the training and support they needed. People were supported to access health care professionals when required. Staff worked well with other agencies to ensure people received care and support.

People said staff were kind and caring. People’s privacy was respected and their dignity maintained. People had food and drink to meet their needs. There were some opportunities for people to follow their interests and hobbies and to be part of the local community.

People were involved in decisions about their care. They were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

People had the opportunity to give their views about the service. There was consultation with staff and people. Their views were used to improve the service. People said they knew how to complain.

A robust quality assurance system was not in place to assess the standards of care in the service. Audits that were carried out were not effective as they had not identified issues that we found at inspection.

Why we inspected: This was the first inspection of the service since it was registered in March 2017. This was a planned comprehensive inspection.

Follow up: We identified concerns at this inspection. We will therefore re-inspect this service within the published timeframe for services rated requires improvement with three requirements.

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