We carried out a review of the data available to us about Victoria Street on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Victoria Street, you can give feedback on this service.
We found the following examples of good practice.
Visits to people were encouraged and staff understood the requirements around this. Visitors were screened for any symptoms of COVID-19 on arrival, had to complete a lateral flow test and there was access to Personal Protective Equipment (PPE). Where required, people were asked to demonstrate their vaccination status.
Staff had access to PPE and wore and disposed of this appropriately.
People were encouraged to access the community and staff undertook a dynamic risk assessment to ensure the environment would be safe and suitable. There was a small staff team who had worked closely together during the COVID-19 pandemic to manage the risks for people.
Staff and resident testing was completed in line with current guidance and the registered manager was clear as to what actions they would take if a person displayed symptoms of COVID-19.
Victoria Street 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 (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.
At the time of this inspection there was no registered manager in post. We were supported by the acting manager who advised us they would be applying to register with CQC within the next month. 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.
At the last inspection on 22 December 2017, we rated the service requires improvement overall and identified two breaches of regulation relating to staffing and the governance of the service. This was because the provider had failed to follow their own policies and procedures to ensure staff were supported through regular training, competency checks, supervision and appraisal of their performance. The provider did not have an effective system in place to assess, monitor and improve the quality and safety of the service provided. Quality assurance systems and audits in place were ineffective.
Following the inspection, the provider submitted an action plan telling us what action they would take to meet the breaches in regulation. At this inspection, we checked and found the provider had completed all the actions. The provider had a schedule in place to ensure all policies and procedures were updated by December 2018, during the inspection we evidenced that some of these had been reviewed and updated. The provider had made sufficient improvements to meet the breaches of regulation 18; Staffing and regulation 17; Good governance.
Staff were receiving regular supervisions and appraisals in line with the providers policies and procedures and future dates had been scheduled.
Staff training had been improved as the provider had sourced further training that staff could complete at their own pace. Records showed that staff had completed safeguarding training and various other courses to further their knowledge and skills. This showed us that the provider was committed to investing in supporting staff to maintain and develop their skills and expertise to encourage better outcomes for people.
The providers’ policies and procedures were being reviewed across the organisation at the time of this inspection. We could see that several policies had been reviewed and updated to reflect current legislation. The area manager told us this was work in progress and as stated in their action plan would be completed by December 2018. An internal audit matrix had been introduced and each area audited had a separate file with details of the audit, areas identified for improvement and the date these were to be completed. A continuous improvement plan was in place to monitor and drive improvements in the service. Records showed external auditors visited every three months to oversee the running and management of the service.
The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.
Staff received medicines training annually and competency checks to ensure the safe administration, storage and disposal of medicines.
Staff could tell us about the different signs and types of abuse and knew how to report any concerns in relation to harm and abuse. Staff had received training in safeguarding adults from harm or abuse.
The provider had systems and processes in place to ensure the environment was safe for people and regularly maintained. Risks to people had been identified and appropriate measures put in place to mitigate them.
Staff worked as a team to ensure shifts were covered by consistent staff that knew people’s needs well. The provider had robust recruitment checks in place to ensure people were of a suitable character to work in a care home setting.
The provider had updated their data protection policies to include the recent changes in legislation. Confidentiality policies had been revised and people, staff and their relatives informed about any changes in terms of how their personal data would be stored and used.
The manager understood their responsibilities as part of their CQC registration and could tell us in which circumstances they were required to inform us of significant events that happen in the service.
Records showed that staff supported people to manage and attend appointments in relation to their health and well-being.
Staff knew the importance of treating people with dignity and respecting their wishes. Observations showed staff knew people extremely well and offered person centred choices and promoted people’s independence.
Staff had a good awareness of people’s nutritional and hydration needs. People were encouraged to make meal choices and had support to prepare meals when needed.
Staff spoke positively about their experiences outside the service when they took people to enjoy various activities of their choice. The provider encouraged sensory activities which stimulated people in a positive way and were constantly looking at ways to improve people’s experiences.
People felt familiar with their community. Staff created a safe environment where people could walk to the shops and feel comfortable in the presence of other people.
Staff adhered to the Mental Capacity Act (MCA) and asked for people’s consent before carrying out care and support tasks. For people who lacked capacity to make decisions for themselves, best interest decisions were arranged with health professionals and relatives input.
We previously inspected this service on 5 November 2015. The service was rated 'Good' overall with 'Requires Improvement' in Well-Led. This was because the provider did not have an effective system in place to assess, monitor and improve the quality and safety of the service provided. This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection, the provider submitted an action plan telling us what action they would take to meet the breach in regulation. At this inspection, we checked and found the provider had not completed all the actions and remained in breach of this regulation.
Victoria Street is a 'care home'. People in care homes receive accommodation and nursing or personal care as 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 service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.
We were supported by staff working at the service on day one of the inspection and on day two by a registered manager. 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 provider had failed to follow their policy and procedure to ensure staff received regular, appropriate supervision and appraisal of their performance to ensure any training, learning and development needs were identified, planned for and supported.
We found people who used the service were not guaranteed quality care and support as ineffective systems were in place to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services).
Medicines were managed, administered and stored appropriately by staff. We could only evidence one medicine competency check completed within the last four months prior to this inspection. Quality assurance checks on medicines management and administration had not been completed. These were addressed by the registered manager and future dates had been scheduled.
Staff protected people from avoidable harm and abuse. They had received training in safeguarding and understood how to report concerns for further investigation. The provider carried out thorough investigations to ensure lessons were learnt.
Checks were completed in and around the environment to ensure the safety of everybody who used the service. Risk assessments had been completed and outlined measures taken to mitigate potential risks using the least restrictive options.
Staffing ratios were appropriate to meet the needs of individuals. Recruitment checks were carried out to ensure suitable people were employed to work with vulnerable adults. Confidentiality policies were in place and the service protected people’s personal information ensuring files were kept in locked cabinets and only those authorised allowed access to them.
The registered manager understood their responsibilities as part of their CQC registration and had informed CQC of significant events that had an impact on the people living at the service. A clear structure was in place and staff were aware of their responsibilities such as raising issues or concerns, so that improvements were made and people were listened to.
People were supported to access appointments with health professionals to maintain their health and wellbeing. Staff treated people with dignity and respect, offering choices and promoting people’s independence. Staff actively encouraged people to participate when cooking healthy meals and made sure that diets were nutritional and balanced.
The service supported people to take part in activities of their choice and links were built within the local community so people could lead fulfilling lives. People were supported to make their own decisions, and when they were unable to make significant decisions alone best interest meetings were arranged to include health professionals and family.
Management and staff understood their responsibilities under the Mental Capacity Act 2005 (MCA). People had consented to their care and support and this was recorded in their care plans.
We found two breaches of legal requirements relating to the on-going governance of the service and staffing under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The inspection of Victoria Street took place on 05 November 2015 and was unannounced. At the last inspection in January 2014 the service was meeting all of the regulations we assessed.
Victoria Street is a residential care home that provides accommodation and support to one adult who may have a learning disability or autistic spectrum disorder. The service is on the edge of the town centre in Goole, East Yorkshire and is just a short walk away from its ‘sister’ service on North Street.
The registered provider is required to have a registered manager in post and on the day of the inspection there was a 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.
People that used the service were protected from the risks of harm or abuse because there were safeguarding systems in place. Staff were trained in safeguarding adults from abuse and they were aware of their responsibilities to make referrals to the local authority safeguarding team.
We saw that people were protected from discrimination on the grounds of disability, by staff that advocated for them whenever necessary. People took reduced risks where possible because of the risk management systems in place to protect them. We found that the premises were safe because they had been regularly maintained using maintenance contracts and the electrical items provided were protected so that people were not at risk.
There were sufficient numbers of staff employed and on duty to safely care for people and to meet their needs. Staff were appropriately vetted to work with vulnerable people. People were protected from receiving the wrong medicines because medication management systems were safely used and followed.
We found that people were supported by trained and competent staff that received induction to their roles, were supervised by the registered manager and took part in an appraisal scheme.
People and staff communicated well and staff sought consent from people to provide them with personal or other care before any support was given. People’s rights were protected because the principles of the Mental Capacity Act 2005 were followed to ensure those without capacity to make decisions were represented according to legal frameworks.
We saw that people’s nutritional needs were met and that people were dependant on staff to provide all of the nutrition and hydration they required. We saw that people’s health care needs were met and advice of health care professionals was accessed whenever necessary to ensure people received the right medical treatment.
People enjoyed premises that were suitable for their purpose. The environment was well maintained and comfortable, but a little sparse in order to reduce the risks of harm to people.
We found that people were cared for and supported by kind and caring staff that also provided clear boundaries for acceptable behaviour. Staff offered advice and guidance to assist people to lead a purposeful and fulfilling life.
We saw that people’s wellbeing was monitored closely by staff and that efforts were made to assist people to improve their wellbeing. We saw that people were cared for in private and their dignity was upheld to a high level.
We saw that people had person-centred care plans in place to instruct staff on how best to support them and meet their needs. These were clearly written, well maintained and regularly reviewed with people’s changing needs.
People were supported to undertake activities of their choosing whenever possible and this was usually on a one-to-one basis. People were able to complain and have their issues satisfactorily resolved, using the service’s complaint procedure.
There was no effective quality assurance system in place to help drive improvement. This was a breach of regulation. You can see what action we have told the registered provider to take at the end of the full version of this report.
We found that people experienced a positive culture at the service and the service aims and objectives were clearly stated. Records that related to people’s personal details and for the running of the service were appropriately kept, maintained and securely stored.
We found that staff were able to communicate well with people who used the service. We saw people asking for meals, drinks and personal care and these requests were promptly responded to. Staff were respectful and patient with individuals. All interactions we saw put the wishes and choices of people who used the service first and they were included in all conversations.
There were robust policies and procedure in place with regard to safeguarding of vulnerable adults from abuse. Staff told us who they would contact if they were concerned about abuse of people who used the service.
The service had a core of permanent staff who had worked at the home since it opened in 2012. These experienced staff knew the needs of people who used the service and were employed in sufficient numbers to be able to meet people's needs.
We saw that the home had systems in place to monitor and review the quality of care. Two relatives told us 'The staff keep us up to date with any changes in X's health and we visit every week so can talk to the staff if we have any concerns.' There was also a complaints system available, which staff and relatives understood and were confident of using if needed.
We found that staff were able to communicate well with people who used the service. We saw people asking for meals, drinks and personal care and these requests were promptly responded to. Staff were respectful and patient with individuals. All interactions we saw put the wishes and choices of people who used the service first and they were included in all conversations.