CQC report explained · a residential care home
What the CQC found at Victoria House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2023
Rated Requires Improvement; inspectors found caring support and enough staff, but important safety and management systems were not reliable.
This was an unannounced focused inspection on 31 October, 1 November and 8 November 2022. Inspectors spoke with people living at the home, relatives, staff and health professionals. They reviewed care and medicines records, recruitment files and management documents.
People told inspectors they felt safe and were happy living at the home. Staff knew people well, treated them kindly and supported activities, independence and relationships. There were enough staff, and the home was clean and tidy.
However, records did not always show that medicines were managed safely. Safeguarding procedures, infection control guidance and recruitment records were not always adequate. Audits had not found these problems, and records did not show that duty of candour steps had always been followed.
The overall rating changed from Good at the previous inspection to Requires Improvement. This inspection only assessed Safe and Well-led. The other ratings were carried over from the previous inspection.
Kind and person-centred support
People and relatives gave positive feedback about staff. People were supported to make choices, personalise their rooms, stay independent and take part in activities.
“People were supported to personalise their bedrooms to reflect their taste and preferences” from the report
Enough staff
Inspectors found enough staff to meet people's needs. Contingency plans were also available if staff could not attend work.
“There were sufficient numbers of staff to safely meet people's needs.” from the report
Clean home
The home was clean and tidy, with enhanced cleaning schedules and enough protective equipment.
“The home was clean, tidy and had no malodours.” from the report
Support for independence
Risk assessments considered people's strengths and needs. Relatives said people were supported to take positive risks and be as independent as possible.
“Relatives confirmed they felt people were supported to take positive risks to be as independent as possible.” from the report
Medicines records
seriousRecords did not always show that medicines were managed safely. Problems included incomplete records for opened creams, fridge temperatures and high use of medicines given when needed.
“Records relating to the management of medicines did not always demonstrate medicines were managed safely.” from the report
Safeguarding arrangements
seriousThe safeguarding policy did not properly explain the provider's responsibilities. Medicine errors had not always been reported to the local authority in line with the reporting thresholds.
“Medicine errors had not been reported to the local authority safeguarding team in line with their reporting thresholds.” from the report
Management checks
seriousAudits had not identified the problems found by inspectors. The provider was also not consistently following suitable policies and procedures.
“A range of audits was completed to monitor quality across the service. They had not identified the issues we found during this inspection.” from the report
Infection control guidance
needs fixingThe infection control policies did not give staff enough detail about safe practices to prevent infections spreading.
“IPC policies and procedures lacked detail to guide staff in the actions to take to ensure they followed safe practices to prevent the spread of infections.” from the report
Recruitment records
needs fixingRecruitment systems were in place, but records did not always show that they had been followed. Some application details did not match CVs and employment gaps were not always explained.
“The reasons for any employment gaps in a candidate's employment history were not recorded on recruitment documentation.” from the report
Duty of candour records
needs fixingThe home worked openly, but written records did not show that all required steps had been taken after notifiable safety incidents.
“Written records were not available to evidence the actions staff had taken to be compliant with the duty of candour regulation.” from the report
- 01What changes have been made to the medicines policy and records since the inspection?
- 02How do you now report medicine errors and other safeguarding concerns to the local authority?
- 03How are audits checking medicines, infection control and recruitment records, and can you show the latest results?
- 04What detailed infection control guidance do staff now follow?
- 05How do you record the actions taken when something goes wrong, including duty of candour requirements?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 25 January 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, September 2019
Victoria House is rated Good; inspectors found safe, kind and person-centred care, with some end-of-life wishes not yet recorded.
This was an unannounced inspection over three visits. One inspector spoke with five people, six staff members and health and social care professionals. Records for seven people and four staff files were checked, along with management records and the home.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, safe medicines systems, person-centred care and good support for people's independence, activities and healthcare.
The home had improved since the previous inspection, which was rated Requires improvement. The earlier breaches about safe care and treatment and good governance had been dealt with, and the home was no longer in breach. Inspectors did note that some discussions about end-of-life wishes had not been formally recorded.
Kind and respectful staff
People said staff were kind, and inspectors observed warmth, compassion and kindness. Staff knew people's histories, preferences and communication needs.
“I like all the staff, the staff are all kind and they help me a lot” from the report
Person-centred support
Care plans reflected people's needs and choices. People were involved in planning their care and were encouraged to make choices and be independent.
“Care plans contained person-centred information which reflected people's needs.” from the report
Safe staffing and medicines
There were enough staff, the staff team was stable, recruitment procedures were followed and medicines records showed people received medicines as prescribed.
“Medicines were managed safely. Medicines records were completed and showed people had received their medicines as prescribed.” from the report
Good links with health services
People were supported to use healthcare services, including annual health checks. Staff followed advice from health and social care professionals and used healthcare companions to coordinate information.
“All recommendations that we have given have been picked up.” from the report
Activities and community life
People were offered activities based on their interests and were supported to attend social events and maintain relationships with family and friends.
“People were offered a range of activities that were specific to their needs, likes and dislikes.” from the report
End-of-life wishes were not all recorded
needs fixingStaff had discussed end-of-life wishes with people, but not all of these discussions had been formally recorded in care plans. The deputy manager said the care plans would be updated.
“All of these conversations had not been formally recorded in care plans.” from the report
- 01Have all residents' end-of-life wishes now been recorded in their care plans, and how are these records kept up to date?
- 02How often are risk assessments reviewed, and what happens when a person's needs or risks change?
- 03How many staff have completed the Care Certificate, and what is the plan for the remaining staff?
- 04How will you support my relative to take part in activities, use the local community and stay in contact with family and friends?
- 05How is information from health appointments recorded and shared with the staff team?
This was an unannounced planned inspection based on the previous rating and covered all five CQC questions, the care provided and the premises. This explanation was written from the published report of 20 September 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 House
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- January 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- August 2018Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2017
Registered with the Care Quality Commission on 24 May 2017.
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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