CQC report explained · a residential care home
What the CQC found at Victoria Road
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 weaknesses in COVID-19 precautions, risk records, incident reporting and medicines management. They also found people were placed at risk of abuse through poor recording and follow-up of incidents.
- Effective?
- Requires improvement
- Mental capacity and best-interest records were incomplete, and staff did not always understand DoLS arrangements. Oral healthcare records and communication training were also incomplete, although staff supported access to healthcare and followed food and fluid guidance.
- Caring?
- Requires improvement
- People's views, life histories, wishes and preferences were not consistently recorded or followed through. Inspectors also found that people had privacy and were encouraged to be independent.
- Responsive?
- Requires improvement
- Care plans did not consistently record people's goals or how to achieve them. Staff lacked training in one person's sign language, and a complaint had no recorded outcome.
- Well-led?
- Requires improvement
- The provider's checks and audits had not found or prevented several important problems. The registered manager responded positively, and staff said they felt able to raise concerns and share ideas.
What inspectors found, August 2021
Victoria Road was rated Requires Improvement; inspectors found risks in medicines, records, safeguarding and infection control.
This was an unannounced inspection over 19, 21 and 22 July 2021. One inspector visited the home on one day, then made telephone calls and gathered more evidence over two days. Inspectors spoke with one person and seven staff, and reviewed care, medicines, recruitment and management records.
All five areas were rated Requires Improvement: Safe, Effective, Caring, Responsive and Well-led. Inspectors found problems with COVID-19 testing and mask use, risk assessments, medicines records, incident records, complaints, recruitment checks and care planning.
The report says people were at increased risk of harm, although inspectors found no evidence that anyone had been harmed. Staff understood safeguarding, supported people to be independent and worked with health professionals. The new registered manager was open about the problems and had started making changes.
The previous rating under the former provider was Good, published on 18 January 2019. This inspection was of a newly registered service, so it provides a new assessment of the home.
Staff understood safeguarding
Staff could explain what safeguarding meant and what they would do if they suspected abuse.
“Staff had a good knowledge of what safeguarding meant in their role and were able to tell us what action they would take if they felt some one was being abused.” from the report
Support for independence
People had privacy in their own flats and staff encouraged them to take part in everyday tasks.
“Staff told us they supported and encouraged people to be independent and be involved in cleaning and cooking.” from the report
Health professional involvement
Staff worked with GPs and community professionals, and supported people to access healthcare.
“Staff supported people to manage their health needs and supported them to access the necessary healthcare services.” from the report
Medicines were not reliably recorded
seriousCreams and liquid medicines had no open dates, and tablet stock records did not show whether people had received medicines as prescribed. Staff also had mixed knowledge of as-needed medicines.
“There were no records to indicate how many prescribed tablets people in stock. This meant there was no way to know if people had received their tablets as prescribed.” from the report
Risks and incidents were not followed up
seriousKnown risks were missing from some care plans. Inspectors also found records of head-hitting without evidence that medical attention had been sought, and incident forms lacked important detail.
“People's known and historical risks were not consistently recorded in their care plans.” from the report
Safeguarding concerns
seriousRecords about as-needed medicines and possible restrictive practices were not detailed or properly investigated. CQC raised a safeguarding alert and found a breach.
“Whilst there was no evidence anyone had been abused, these practices placed people at risk of abuse.” from the report
COVID-19 controls were incomplete
seriousNot everyone was tested as required, some staff were not wearing masks in line with guidance, and infection-related risk assessments were insufficient.
“Staff and people were not all being tested for COVID-19 in line with government guidance.” from the report
Care was not consistently person-centred
needs fixingPeople's wishes, goals and life histories were not consistently recorded. There were missed opportunities to understand emotions and support communication.
“People's wants, needs and goals were not consistently recorded.” from the report
Complaints records were incomplete
needs fixingA complaint had been recorded without an outcome, and care plans did not explain how people could complain.
“One complaint had been recorded but there was no recorded outcome about what action had been taken to manage this.” from the report
- 01What has been changed to make medicines records complete, including open dates, tablet stock checks and records for as-needed medicines?
- 02How are you now recording and reviewing people's known risks, incidents and any need for medical attention?
- 03What action was taken after the warning notice about governance, and how do audits now show that improvements are working?
- 04What communication training do staff now have, including support for people who use sign language or communicate without speech?
- 05How are people's goals, wishes, complaints and outcomes now recorded and reviewed with them?
This was an unannounced inspection of all five key questions, including infection prevention and control, at a newly registered service. This explanation was written from the published report of 20 August 2021 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 Road
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- August 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2019Goodstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2019
Registered with the Care Quality Commission on 12 August 2019.
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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