CQC report explained · a residential care home
What the CQC found at Victoria Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Requires Improvement; inspectors found safe care, but weak management checks created risks and Regulation 17 was breached again.
This was an unannounced focused inspection on 24 and 27 January 2023. One inspector and an Expert by Experience spoke with people, relatives, staff and professionals, observed care, and checked care, medicines, recruitment and management records.
The safe rating improved from Requires Improvement to Good. Inspectors found enough trained staff, safe medicines practice, suitable risk plans, good infection control and people protected from abuse. Earlier concerns about medicines and mental capacity assessments had been addressed.
The well-led rating remained Requires Improvement. Important checks and audits were not completed regularly, including health and safety, infection control, risk assessments and key worker meetings. The home had no registered manager during the inspection, although a new registered manager was appointed afterwards.
Safe medicines support
Medicines were administered, recorded and stored safely, with no errors or unexplained gaps found in the records. Earlier recommendations about medicines had been acted on.
“We found no errors or unexplained gaps in recording on medicine administration records (MAR).” from the report
Enough familiar staff
People and relatives said there were enough staff. People were supported by a regular team who knew them well.
“People and their relatives told us there were enough staff to meet their needs.” from the report
Respectful, person-centred support
People were supported to make choices, and staff respected consent and personal preferences. Inspectors found a positive and friendly atmosphere.
“The management team promoted a positive culture, which supported the delivery of person centred care and support.” from the report
Earlier improvements
The home had improved its approach to medicines and mental capacity assessments since the previous inspection.
“At this inspection we found the provider had acted on these recommendations and improvements had been made.” from the report
Inconsistent management checks
seriousKey audits and checks were not completed regularly. This meant the home could not reliably show that quality and possible safety problems were identified and acted on.
“Governance systems were not being completed regularly to ensure quality and potential safety issues were identified and acted upon.” from the report
Water safety checks
seriousLegionella checks were not up to date, and records did not show action after some high water temperatures were found. The acting manager dealt with this during the inspection and checks resumed.
“We found regular checks to manage the risk of legionella had not been kept up to date and where water temperature checks had identified some high temperatures within the service, there was no record of action taken in response.” from the report
- 01Has a registered manager now taken up post, and how is management cover arranged?
- 02How often are health and safety, infection control and other service audits now completed, and can you show the latest records?
- 03How are legionella and water temperature checks being monitored, and what happens when a high temperature is found?
- 04How often are people's risk assessments reviewed when their needs change?
- 05Are key worker meetings now recorded, and how is the quality of support discussed in those meetings checked?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 19 April 2023 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, July 2019
Rated Requires Improvement; inspectors found kind, person-centred care, but medicine records and quality checks were not reliable.
This was a planned inspection over 4 and 6 June 2019. One inspector visited, spoke with people, staff, a relative and health and social care professionals, and checked care records, staff files, medicines, incidents, complaints and management records.
People were supported in a clean, homely setting by caring staff. Care was personalised. People were supported with daily living skills, activities, food, healthcare and making choices. The ratings for Effective, Caring and Responsive were Good.
The Safe rating fell from Good to Requires Improvement. Medicine records were not always complete, one person's diabetes risk guidance was missing until the second day, and there were staff vacancies. The Well-led rating remained Requires Improvement because quality systems had not ensured that known actions were completed.
The overall rating was Requires Improvement. The provider breached Regulation 17 on good governance. CQC asked for an action plan, said it would monitor progress with the provider and local authority, and planned to return.
Kind and respectful care
People were treated kindly and positively. Staff respected privacy, dignity and individual choices.
“People were supported by staff who were kind and caring.” from the report
Person-centred support
Care plans included people's histories, preferences and communication needs. Staff knew this information and used it in daily support.
“Care and support were person centred and reflected people's individual choices and wishes.” from the report
Independence and activities
People were supported to build skills, make choices and take part in activities that mattered to them.
“The service had a flexible approach to supporting people in activities and interests which took account of how people were feeling on a day to day basis.” from the report
Clean and accessible home
The home was clean and tidy, with recent improvements to the kitchen and hallways. Information was provided in formats people could understand.
“The service was clean and tidy. Recent refurbishment had occurred of the kitchen and hallways.” from the report
Medicine records
seriousMedicine quantities had not always been signed in on the medicine records. When signatures were missing, the records did not clearly show how staff had checked that an error had not occurred.
“However, where there had been missed signatures on the MAR it was not clearly documented how it had been determined that a medicine error had not occurred.” from the report
Risk information
seriousOne person did not have guidance for staff about risks linked to their diabetes care. This issue had also been identified at the previous inspection.
“One person did not have a procedure in place around potential risks related to their diabetes care.” from the report
Quality checks
seriousThe home's monitoring systems did not reliably make sure that identified improvements were completed. This contributed to the breach of Regulation 17.
“We found no evidence that people had been harmed however, systems were not fully effective in ensuring actions were completed in a timely way.” from the report
Capacity decisions
needs fixingSome mental capacity assessments and best interest decisions had not been reviewed regularly, including decisions about medicines and personal care.
“However, where capacity assessments had been undertaken and associated best interest decisions made, these had not been regularly reviewed to ensure they remained appropriate.” from the report
Staff vacancies
needs fixingSupport worker and shift leader vacancies were being covered by existing and bank staff. A staff member said the team was short and senior staff workload had increased.
“Current vacancies were being covered by existing and bank staff members.” from the report
- 01How are medicine records now checked, and how do you investigate and prevent missed signatures?
- 02What current written guidance is in place for the person's diabetes-related risks, and how is it reviewed?
- 03How often are mental capacity assessments and best interest decisions reviewed, especially for medicines and personal care?
- 04Have the support worker and shift leader vacancies been filled, and how do you make sure staffing levels remain safe?
- 05What actions were included in the response to the Regulation 17 breach, and what evidence shows that those actions were completed?
This was a planned inspection covering all five key questions, with the first day unannounced and the second day announced; CQC looked at the accommodation and the care provided. This explanation was written from the published report of 24 July 2019 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 Court
4 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- April 2023Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 10 December 2010.
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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23 live-in carers within about an hour of North Somerset
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,050 to £1,320 a week. 19 can care for a couple. 12 years' experience on average.
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