CQC report explained · a residential care home
What the CQC found at Victoria House Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always managed safely. Inspectors also found gaps in risk records, conflicting care plan information and no formal process for learning from incidents.
- Effective?
- Good
- This question was not inspected during this visit. Its rating carried over from the previous inspection.
- Caring?
- Good
- This question was not inspected during this visit. The report says people and relatives liked the staff and inspectors observed positive interactions.
- Responsive?
- Good
- This question was not inspected during this visit. Its rating carried over from the previous inspection.
- Well-led?
- Requires improvement
- Quality monitoring was not robust enough. Audits had failed to identify medicines and care plan problems, and some environmental issues had not been dealt with.
What inspectors found, December 2022
Victoria House Residential Home was rated Requires Improvement; inspectors found unsafe medicines practices and weak checks on care and the environment.
This was an unannounced focused inspection. Inspectors visited on 21 and 23 November 2022, spoke with people, relatives and staff, observed care, and checked care files, recruitment records and quality checks.
The home was not always safe. Medicines were not managed properly, some risks and changing care needs were not clearly recorded, and there was no formal process to learn from incidents. Quality checks had not identified or dealt with some of these problems.
There were also positive findings. Staff knew people's needs, people and relatives described staff as caring and approachable, infection control was good, and there were enough staff at the time. The overall rating fell from Good at the previous inspection to Requires Improvement because of this inspection's findings. The inspected ratings for Safe and Well-led were Requires Improvement.
Caring staff
People and relatives found staff caring and approachable. Inspectors saw positive interactions between staff, people and relatives.
“People and relatives liked the staff who supported them and felt they were caring and approachable.” from the report
Staff knew people's needs
Staff were knowledgeable about people's current needs and supported people with appropriate equipment and clear guidance where needed.
“Despite this, staff we spoke with were very knowledgeable about people's current needs.” from the report
Infection control
Inspectors were assured that the home used suitable infection prevention measures, including safe use of protective equipment and procedures for outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safeguarding
There were processes to protect people from abuse. Staff had safeguarding training and worked with local authority teams when concerns were raised.
“There were systems and processes in place to ensure people were protected from the risk of abuse.” from the report
Choice and involvement
The home promoted choice and involved people, relatives and staff through meetings, questionnaires and an open approach.
“The registered manager worked in an open way promoting choice and person-centred care for people.” from the report
Medicines were not always safe
seriousInspectors found missed tablets left in a trolley, incomplete controlled-drug records, unsuitable storage and unsigned handwritten prescription entries. These problems could increase the risk of medicines being given incorrectly or misused.
“People's medicines were not always managed safely.” from the report
Care and risk records were unclear
needs fixingSome care plans had not been updated when people's needs changed. There were also missing records about why some environmental safety measures were in place.
“There was conflicting information in some people's records when there had been changes to their needs as some parts of their care plans had not been updated.” from the report
Weak quality checks
seriousAudits did not reliably identify problems, and issues found in an environmental audit had not been addressed. This was linked to a breach of the governance regulation.
“Quality monitoring processes were not always robust.” from the report
Limited formal learning from incidents
needs fixingStaff discussed incidents informally, but there was no formal system for recording and sharing what had happened to improve care.
“They told us they talked about incidents between themselves but there was no formal way of recording and sharing events to improve outcomes for people.” from the report
Staff were covering extra shifts
needs fixingThere were enough staff during the inspection, but the rota showed extra hours and staff taking on several roles. The home was trying to recruit more staff.
“However, the duty rota showed staff were working extra hours to cover shifts, and staff were required to take on multiple roles to ensure people were well cared for.” from the report
- 01What changes have you made to medicines storage, controlled-drug records and medicines given when needed?
- 02How do you now check that handwritten medicine entries are accurately copied and signed?
- 03How do you make sure care plans and risk assessments are updated promptly when a person's needs change?
- 04What formal system do you use to record incidents and show what has been learned?
- 05How are staffing levels maintained without relying on staff and the manager to work extra shifts?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 29 December 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, January 2020
Victoria House Residential Home was rated Good; inspectors found kind, safe care, but some medicine records were inconsistent.
This was an unannounced inspection on 12 November 2019. One inspector spoke with people, a relative and staff, observed care, and checked care, medicine and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, suitable training, clean surroundings, personalised care and support for people's dignity, independence and choices.
There was one shortfall. Some medicines needing two staff signatures were not recorded consistently and staff did not always follow the home's procedure. The provider said it had corrected this, and later provided details of the action taken.
Kind and respectful care
Staff supported people's dignity, independence and personal preferences. People and relatives said staff were approachable and caring.
“The provider and staff were kind and caring and supported people's dignity and independence.” from the report
Enough staff
People told inspectors there were enough staff to meet their needs. Recruitment checks and safeguarding training were also in place.
“People told us that there were enough staff to meet people's needs.” from the report
Personalised care
People and relatives were involved in care planning. Plans accurately described people's needs and were reviewed each month.
“Care plans accurately reflected people's care needs and records showed that they had been reviewed on a monthly basis.” from the report
Support for independence
The home adapted meals, drinks and equipment to help people do as much as possible for themselves. Staff also supported safe eating and mobility.
“Meals were presented so people were able to eat independently, for example, some people chose to have their lunch in a bowl instead of on a plate.” from the report
End-of-life wishes
People and relatives were supported to discuss and record their wishes. Staff worked with other services to help keep people comfortable and pain free.
“Staff had liaised with other agencies to ensure that all medical care was available.” from the report
Medicine records
needs fixingRecords were not always completed consistently when two staff signatures were required, and staff were not always following the home's procedure. The provider said it had taken action after the inspection.
“We saw that there were some inconsistencies in how medicines which required two staff signatures were recorded and the staff were not working in line with the provider's protocols.” from the report
- 01What exact changes were made to the records for medicines requiring two staff signatures?
- 02How do you now check that staff follow the medicine recording procedure every time?
- 03How would you meet my relative's specific mobility, eating and communication needs?
- 04How are relatives involved in reviewing care plans and decisions about end-of-life care?
- 05What activities and support would be available to help my relative maintain relationships and interests?
This was an unannounced inspection that looked at all five CQC questions, including the care provided and the home's premises. This explanation was written from the published report of 17 January 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 House Residential Home
4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- December 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Victoria House Residential Home →
- January 2020Goodstayed GoodSafe: GoodWell-led: Good
Read what inspectors found at Victoria House Residential Home →
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 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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