Victory Socialcare Enterprise

Victory Social Care Enterprise is a residential care service providing accommodation to a maximum of 12 people, some of whom are living with dementia. At the time of this inspection there were 10 people using the service.

People’s experience of using this service and what we found

At the time of the inspection, the location did not care or support for anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.

Right Care:

The provider had not ensured all staff were suitably trained or supported to perform their roles. Some staff required refresher training to ensure they had the knowledge and skills to safely meet people’s needs. Staff did not receive regular supervision; however, staff felt the registered manager was supportive and approachable.

Staff did not always follow risk assessments effectively.

Medicines were managed safely however, guidance for staff relating to medicines which were prescribed on an ‘as and when required’ basis (PRN) needed more detail.

There were enough staff. Staff were recruited safely and received an induction to ensure they had the skills and knowledge to undertake their role.

Right Support:

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Care plans were being updated to ensure people received person centred care.

The service gave people care and support in a safe, clean, well-furnished environment. People were supported to make decisions following best practice in decision making and staff communicated with people in ways that met their needs.

Right Culture:

The ethos, values, attitudes and behaviours of management and care staff were working towards ensuring people using services led confident, inclusive, and empowered lives. The provider worked closely with the local authority to create an action plan to improve the service and to embed these changes within practice however, further improvements were needed to ensure changes were fully embedded in practice. We have made a recommendation about this.

People and those important to them were involved in planning their care and staff evaluated the quality of care supported to people, involving the person, their families and other professionals as appropriate.

Systems were in place for communicating with people, their relatives and staff to ensure they were fully involved. Feedback from people and their relatives was positive. Relatives told us they were happy with the service and care given.

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

Rating at last inspection and update and update

The last rating for this service was requires improvement (published 07 May 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 we found the provider remained in breach of regulations.

The last rating for this service was requires improvement (published 07 May 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

Enforcement and Recommendations

We have identified breaches in relation to assessing risk, staff training, staff supervision and poor-quality assurance systems.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Victory Socialcare Enterprise provides domiciliary care to people living in their own homes as well as short-term residential care for up to 12 older people recovering from illness. There were 15 people receiving the care at home service when we inspected. There were five people using the residential service recovering from illness after being in hospital and being supported with personal care before they go home.

Not everyone using Victory Socialcare Enterprise receives a regulated activity. The Care Quality Commission (CQC) only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided. People in the residential respite service were all provided with ‘personal care’, but some living in their own homes were not.

People’s experience of using this service:

People were not always protected from risks. This meant they could be harmed if staff were unaware of how to reduce risks because of unclear information in risk assessments or there being none in place to refer to. The provider responded to our findings by day two of the inspection and risks were reduced.

Medicines were not safely managed. People could be harmed if they did not receive their medicines because of problems with stock control and administration. Poor recording did not help identify these problems. We made a recommendation about following medicines guidelines.

People were not supported to have maximum choice and control of their lives and staff did not support this practice. People did not always have their ‘best interests’ protected by the use of robust mental capacity assessments and documentation. We made a recommendation about implementing the 'best interest' process and keeping accurate records of it.

Quality assurance systems did not always improve the quality of the support people received, which meant they were at risk of receiving poor care. Some checks that were usually carried out to show this, had lapsed. There was no quality monitoring plan to help drive the systems that were in place and some quality checks were poorly completed. The provider produced a quality monitoring plan and revived the quality checks immediately after our inspection.

Systems were in place to safeguard people from harm and abuse and staffing numbers were sufficient to meet people’s needs with contingency emergency cover arrangements in place. Staff were recruited safely, as references and checks had been completed. The prevention and control of infection was managed well and staff were careful to maintain good hygiene standards. The provider and staff learnt lessons from the mistakes that were made.

People across both areas of the service had their needs assessed and recorded and staff undertook appropriate training to enable them to carry out their roles. People experienced good support with nutrition and maintaining their health, staff worked well with other agencies and the premises for the residential service were suitable for meeting people’s needs.

The service involved people and treated them with compassion, kindness, dignity and respect.

The service met people’s needs because staff were responsive to wishes, likes and preferences. Organisation and delivery of the support given to people were also responsive. Staff were responsive to people’s needs around care and support plans, complaints and end of life care.

The provider tried to give people person-centred, high quality care. Outcomes for people were generally good. The provider understood their responsibility to be open and honest. They engaged and involved people using the service, the public and staff, and fully considered everyone’s individual needs.

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

Rating at last inspection:

Good for the domiciliary care part of the service (last report published 27 July 2016).

Why we inspected:

This is the first rated inspection of the service since the provider moved premises and opened the residential service in addition to the domiciliary care service.

Enforcement:

We have identified three breaches in relation to management of medicines, people's rights and effective quality assurance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.