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
- Inspectors found unlocked thickening medicine, medicines guidance that did not match prescriptions, incomplete records for some PRN medicines and overdue equipment safety checks. Recruitment systems had been strengthened and staff numbers were found to meet the dependency tool, although the provider was asked to review it.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its rating carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its rating carried over from the previous inspection, although inspectors recorded positive feedback about the care and culture.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its rating carried over from the previous inspection.
- Well-led?
- Requires improvement
- Audits did not reliably identify problems or show what action had been taken after incidents. This included missed notifications, overdue equipment checks and medicine issues.
What inspectors found, September 2022
Victoria House Residential Home was rated Requires Improvement; inspectors found medicine, equipment safety and management checks needed strengthening.
This was an unannounced, focused inspection after concerns about staff recruitment. Inspectors visited on 12 July 2022, spoke with people, relatives and staff, and checked care, medicine, recruitment and management records.
The home was rated Requires Improvement for Safe and Well-led. Inspectors found risks from unlocked thickening medicine, medicines guidance that did not match prescriptions, incomplete incident follow-up and overdue equipment safety checks.
There were also positive findings. Staff knew how to report safeguarding concerns, recruitment checks had been strengthened, people were supported to make choices, and the home was visibly clean. Some infection control problems were corrected promptly.
The previous overall rating was Good, published in March 2019. Because this inspection only assessed Safe and Well-led, the other ratings carried over from the previous inspection. The overall rating fell to Requires Improvement.
Recruitment checks
Inspectors found that recruitment systems had been strengthened so checks were completed before staff started work.
“During the inspection we found systems and processes had been strengthened to ensure the safe recruitment of staff was taking place.” from the report
Choice and least restriction
People were supported to make choices and were cared for in their best interests and with the least restriction needed.
“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” from the report
Positive care culture
People and relatives gave positive feedback about the care. Staff were described as caring, committed and responsive.
“People benefitted from a positive and person-centred culture at Victoria House Residential Home.” from the report
Infection control response
The home was visibly clean and staff used protective equipment correctly. Problems found during the inspection were dealt with promptly.
“Staff wore appropriate personal protective equipment (PPE) when supporting people and had completed training in the prevention and control of infection.” from the report
Medicine storage and instructions
seriousThickening medicine was left unlocked in a communal area. Some instructions for medicines given when needed did not match the prescriptions, and reasons were not always recorded.
“We found several containers of 'thickener' left in a communal area, not locked away.” from the report
Overdue equipment checks
seriousSome equipment had not been checked for more than five months, and one bed had not been safety checked since 2019. This created a risk because the checks were needed to confirm equipment remained safe.
“some equipment had been without a safety check for over five months, we found one bed had not been safety checked since 2019.” from the report
Weak management monitoring
seriousThe provider's audits did not identify important problems or record the action taken after incidents. The CQC found this put people at risk and breached good governance requirements.
“The provider had failed to effectively establish and operate systems to assess, monitor and improve quality and safety of the services provided which put people at risk.” from the report
Incomplete notifications
needs fixingNot all required safeguarding and CQC notifications had been sent. The provider was asked to send them retrospectively.
“The registered manager understood their responsibility to share safeguarding concerns with the local authority and CQC but not all appropriate notifications had been sent when necessary.” from the report
Minor infection control issues
minorInspectors found dirt behind a toilet and a rusty microwave. These problems were dealt with promptly, but the home also needed some refurbishment.
“We identified some IPC issues. For example, we found dirt behind a toilet and a rusty microwave.” from the report
- 01What action has been completed to keep thickening medicines locked away, and how is this checked now?
- 02How do you make sure instructions for medicines given when needed match each person's prescription?
- 03Are all beds, lifting equipment and other safety-critical equipment now checked on time, including the bed that had not been checked since 2019?
- 04What changes have been made to audits so incidents, safeguarding referrals and CQC notifications are followed up and recorded?
- 05How have staffing levels been reviewed against people's changing needs since the inspection?
This was an unannounced focused inspection of Safe and Well-led after recruitment concerns; the other key question ratings carried over from the 2019 inspection. This explanation was written from the published report of 7 September 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, March 2022
Inspected but not rated; inspectors found mostly good infection control, but communal areas did not always support social distancing.
This was an announced, targeted inspection on 8 February 2022. Inspectors looked at infection prevention and control during the COVID-19 pandemic, and asked about staffing pressures.
Inspectors found infection control audits and policies in place. Staff had infection control training, visitors followed an entry protocol, and testing was available for staff and residents. Inspectors were assured about most infection control arrangements.
The inspection did not give an overall quality rating. The Safe question was inspected but not rated, so this report does not provide a full judgement on the quality of care.
Infection control systems
The home had infection control audits and policies. Staff had completed relevant training.
“Infection prevention and control audits were completed, and infection prevention and control policies were in place.” from the report
PPE checks
The manager carried out spot checks to make sure staff used protective equipment correctly.
“The registered manager conducted regular spot checks to ensure staff were following the correct procedures when donning and doffing their personal protective equipment.” from the report
Testing and outbreak management
There was a testing system for staff and residents, intended to identify infection early. Inspectors were assured that outbreaks could be prevented or managed effectively.
“There was a testing regime in place for staff and people living in the service.” from the report
Healthcare links
The home had established working relationships with relevant healthcare professionals, and their support continued during the pandemic.
“The service had established good working relationships with relevant healthcare professionals and their support continued during the pandemic.” from the report
Social distancing in communal areas
needs fixingCommunal areas did not always make it possible for people to keep apart. Inspectors signposted the provider to resources to improve its approach.
“The communal areas did not always facilitate people to socially distance.” from the report
Shielding and distancing assurance
needs fixingInspectors were only somewhat assured that shielding and social distancing rules were being met.
“We were somewhat assured that the provider was meeting shielding and social distancing rules.” from the report
- 01What changes have been made to communal areas since the inspection to support social distancing?
- 02How do you currently manage shielding and social distancing for residents who need extra protection?
- 03How are staff and visitors checked for COVID-19 and other infection risks before entering?
- 04How do you check that staff use PPE correctly in practice?
- 05What were the results of recent infection prevention and control audits?
This was a targeted inspection of infection prevention and control and staffing pressures; it did not provide ratings for the other four questions or an overall quality rating. This explanation was written from the published report of 3 March 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.
Every inspection of Victoria House Residential Home
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Victoria House Residential Home →
- March 2022Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Victoria House Residential Home →
- March 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- January 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 18 May 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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