CQC report explained · a nursing home
What the CQC found at Victoria Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2022
Victoria Care Home was inspected but not rated; inspectors found good infection control during a COVID-19 outbreak.
This was an announced, targeted inspection on 2 February 2022. Inspectors looked at infection prevention and control and asked about staffing pressures linked to COVID-19.
Inspectors found that visitors and professionals had to meet testing or vaccination requirements. Staff used protective equipment, the home was clean, and there were supplies of protective equipment. People were tested regularly and new admissions had to isolate safely.
The home was in outbreak status and closed to non-essential visitors at the time. Inspectors found measures to reduce mixing, support isolation and protect people from infection. They were also told there were enough staff, although agency nurses covered a small number of night shifts.
This report does not give an overall quality rating. Safe was inspected but not rated, and the other four areas were not assessed in this inspection.
Infection control
Inspectors found effective arrangements for preventing and managing infection, including testing, protective equipment, cleaning and safe isolation.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Safe visiting arrangements
Visiting took place in agreed areas, with checks for negative tests and vaccination evidence. The home considered people's wellbeing when limiting visits.
“People's individual needs had been assessed, and the impact of not seeing visitors would have on their wellbeing.” from the report
Clean environment
The home was visibly clean and touch points were cleaned regularly throughout the day.
“Regular cleaning of all touch points and other key areas were carried out throughout the day.” from the report
Staffing cover
The provider told inspectors there were enough staff to cover sickness, holidays and COVID-19 isolation. The same agency nurses were used for the night shifts that needed cover.
“There were enough staff to support people safely and to cover any staff holidays, sickness and COVID-19 isolation.” from the report
Safe admissions
New residents had to meet testing, vaccination and isolation requirements before entry, with extra support during isolation.
“The provider had processes in place that ensured the safe admission of new people to the home.” from the report
Visitor restrictions during outbreak
needs fixingThe home was closed to non-essential visitors while it was in outbreak status. Families should check what visiting arrangements are currently in place.
“The home was currently in 'Outbreak status' meaning the home was closed to non-essential visitors until the home was clear of COVID-19.” from the report
Isolation for people with dementia
needs fixingThe report says isolation could be difficult for people living with dementia. The home provided extra staff support, but families should ask how this is managed in practice.
“It was acknowledged isolation for people living with dementia was difficult at times.” from the report
- 01What are the current visiting arrangements, and what happens if the home has another COVID-19 outbreak?
- 02How will you support a person living with dementia if they need to isolate in their room?
- 03How often are staff and residents tested now, and what happens when someone has a positive result?
- 04When are agency nurses used on night shifts, and how do you make sure they know each resident's needs?
- 05How are infection control audits and action plans reviewed, and can families see the results?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; the other quality areas were not assessed and Safe was inspected but not rated. This explanation was written from the published report of 12 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2020
Rated Good; inspectors found safe, well-led care, but recommended improvements to medicines instructions and record keeping.
This was a focused inspection on 29 October 2020. Inspectors looked only at Safe and Well-led. They spoke with relatives and staff, observed care, and reviewed care, medicines, cleaning and management records.
The home had enough staff according to inspectors, and risks such as choking, diabetes and skin damage were assessed. Medicines were given safely, although some instructions for medicines given when needed did not contain enough detail. Infection control was generally effective, with a small issue about how some protective equipment was disposed of.
The home was judged well-led. Audits, meetings and reviews were being used to improve care. However, managers needed better oversight of delegated work, and some records had gaps or contained sensitive information.
The overall rating was Good. Safe and Well-led both improved from Requires Improvement at the previous inspection, and the home was no longer in breach of regulations 12 and 18. Effective, Caring and Responsive were not inspected during this visit, so their previous ratings carried over.
Staffing
Inspectors found enough staff to support people's needs across the home. Staff were observed responding appropriately and showed knowledge of the people they cared for.
“Sufficient numbers of staff to cover and support people's needs were deployed across all areas.” from the report
Managing choking risks
The home had introduced meal-time checks and clearer dietary systems since the previous inspection. These changes were intended to help people at risk of choking.
“Since the last inspection in November 2019 the provider had put meal time observations checks in place.” from the report
Infection control
The home was clean and protective equipment was generally used safely. Staff had up-to-date infection control training and the service carried out regular COVID-19 testing.
“The service was clean and tidy. There was a head housekeeper and a team of domestics who understood how to protect people from the risk of infection.” from the report
Quality monitoring
Inspectors found robust audits and monthly reviews. The provider used these to identify issues and respond to them.
“Robust quality audits were carried out to identify issues and how to address these.” from the report
Medicines given when needed
needs fixingSome instructions did not explain clearly enough why or when certain medicines should be used. The report recommends that these protocols are reviewed.
“Protocols for PRN were in place, but some had limited information.” from the report
Protective equipment disposal
minorProtective equipment was used effectively, but one disposal bin did not meet the guidance described in the report. The manager said this would be addressed.
“However, disposal of PPE was not always in line with government guidance, a pedal bin was being used in the main reception area that did not have any liner.” from the report
Sensitive information in care files
minorInspectors found personal information on one file that should not normally have been stored there. They recommended reviewing care files against the home's data protection policy.
“However, we found some personal information on a file we looked at.” from the report
- 01What changes have you made to the instructions for medicines given when needed, including paracetamol and epilepsy medicines?
- 02How do managers now check that department heads complete all required paperwork?
- 03What checks are in place to make sure sensitive personal information is not kept in care files?
- 04How was the issue with the unlined protective equipment bin resolved?
- 05What are the current ratings and recent inspection findings for Effective, Caring and Responsive, which were not assessed in this visit?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive carried over from the previous comprehensive inspection. This explanation was written from the published report of 19 December 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Victoria Care Home
7 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- December 2020Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- July 2018Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2017Requires improvementstayed Requires improvementResponsive: Requires improvement
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 4 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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