CQC report explained · a residential care home
What the CQC found at Victory Socialcare Enterprise
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were at increased risk because fire safety training and drills were not fully up to date, and staff did not always follow risk assessments. Medicines and infection control were managed safely, but some PRN medicine guidance needed more detail.
- Effective?
- Requires improvement
- Some staff refresher training was overdue and staff had not received supervision in line with the home's policy. Care planning, consent arrangements, nutrition and access to healthcare were otherwise described positively.
- Caring?
- Good
- This key question was not inspected in this follow-up report, so no new rating is given.
- Responsive?
- Good
- This key question was not inspected in this follow-up report, so no new rating is given.
- Well-led?
- Requires improvement
- Quality monitoring was not effective enough to identify and address problems reliably. The provider had an improvement plan and worked with the local authority, but changes were not yet fully embedded.
What inspectors found, May 2023
Requires Improvement; inspectors found staffing, fire safety, risk management and quality checks were not consistently strong enough.
This was an unannounced follow-up inspection on 7 March 2023. One inspector spoke with one person, three relatives and seven staff. They also reviewed care records, medicine records, staff files and management records.
The home was rated Requires Improvement overall, and also Requires Improvement for Safe, Effective and Well-led. Staff numbers and recruitment were suitable, medicines were managed safely, and relatives gave positive feedback. However, fire safety training and drills were not up to date, staff did not always follow risk assessments, and some training and supervision were overdue.
The home remained in breach of Regulation 12 about safe care and treatment and Regulation 17 about good governance. The previous breaches about medicines and consent had been resolved, but the home had been rated Requires Improvement at the two consecutive inspections covered by the report.
Enough staff
Inspectors found staffing levels were suitable for people's needs. Recruitment checks were also completed safely.
“Appropriate staffing levels were in place to meet the needs of people in the service.” from the report
Medicines improved
Medicines were managed safely and staff had their medicine skills checked. The home was no longer in breach of the medicines regulation.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Consent and rights
Care plans reflected the Mental Capacity Act, and appropriate applications had been made where restrictions were needed.
“People's rights were protected, assessments had been completed when people lacked capacity and best interest meetings were held” from the report
Positive family feedback
Relatives said they were happy with the care, communication, staff and management. They said they could raise concerns with the management team.
“Relatives told us they were happy with the service, communication, staff and management.” from the report
Fire safety and risk controls
seriousSome staff had not completed fire safety training or regular fire drills. Emergency evacuation plans were not kept in the fire grab bag, and staff did not always follow risk assessments.
“People were placed at risk of harm because staff had not received full fire safety training as per fire policy and staff had not completed regular fire drills.” from the report
Overdue training and supervision
needs fixingSome refresher training was out of date, and staff supervision had not taken place as required by the home's policy.
“The provider had not ensured all staff were suitably trained or supported to perform their roles.” from the report
Weak quality checks
seriousThe home's monitoring systems had not reliably picked up or fixed problems with fire safety, training, supervision and risk assessments. The home remained in breach of the good governance regulation.
“The provider had failed to complete effective monitoring of the quality and safety of the service.” from the report
Incomplete PRN guidance
minorSome instructions for medicines given when needed did not contain enough information for staff.
“Guidance for staff to administer medicines prescribed 'as and when required' (PRN) were in place however, some protocols required further information to be included to aid staff.” from the report
- 01Have all staff now completed their fire safety refresher training and regular fire drills?
- 02Where are residents' personal emergency evacuation plans kept, and can staff access them immediately in an emergency?
- 03How do you check that staff are following each person's risk assessments, including the hot water urn risk?
- 04Have all staff received supervision as required by your policy, and how do you record and follow up this supervision?
- 05What changes have you made to your quality monitoring system to prevent the same problems happening again?
This was an unannounced follow-up inspection after the 2019 inspection, focusing on Safe, Effective and Well-led; the report says ratings for key questions not inspected carry over from the last inspection. This explanation was written from the published report of 3 May 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
Requires Improvement; inspectors found kind and responsive care, but medicines, risk records, people's legal rights and quality checks were not always managed safely.
The inspection took place on 26 April, 30 April and 7 May 2019. One inspector visited the office and respite care home, spoke with people and staff, reviewed records and made telephone calls to people receiving care at home.
The home provided short-term residential care for up to 12 older people recovering from illness, as well as domiciliary care. Inspectors found caring and responsive support, suitable staffing, good infection control and appropriate support with food, health and appointments.
There were important shortfalls. Medicines were not always managed safely. Risk assessments were incomplete or unclear. Mental Capacity Act records and best-interest decisions were not always properly completed. Quality checks had lapsed or failed to identify these problems.
The overall rating was Requires Improvement. Safe, Effective and Well-led were also rated Requires Improvement. Caring and Responsive were rated Good. The provider took some action during and immediately after the inspection, but the CQC said it would continue to monitor the service.
Kind and respectful staff
People described staff as caring and helpful. Inspectors saw staff respect people's privacy, dignity and independence.
“Staff were kind, caring and considerate. They demonstrated good understanding of people's diverse needs” from the report
Personalised support
Care plans included people's preferences, likes, dislikes, social needs and cultural needs. People and relatives had input into the plans.
“People's support plans contained clear information on how care was to be delivered in line with their preferences, likes and dislikes.” from the report
Support with health and nutrition
People had choices about food and received help to maintain healthy lifestyles. Staff worked with health professionals when needed.
“People were effectively supported with their dietary needs and making healthy choices with their nutritional intake and diets.” from the report
Good infection control
Inspectors found that staff followed good hygiene and food safety practices.
“People were protected from the risks of harm by staff operating good infection control and prevention practices.” from the report
Medicines were not always safe
seriousStock counts and medicine records were inaccurate. Some medicines were not given on the day matching their labels, and refusals were not always recorded properly. Inspectors said this put people at risk of harm.
“At the care home people were at risk of not receiving their medicines as prescribed and we were unable to determine if they had received them correctly.” from the report
Risk information was incomplete
seriousSome risk assessments were missing or did not explain how risks had been decided. Changes in people's needs were not always followed by updated assessments and action.
“People were not always protected from the risk of avoidable harm. Risk assessments were used, but not in place to cover all areas.” from the report
Mental capacity records were not robust
seriousCapacity assessments and best-interest decisions were poorly recorded. Inspectors found no evidence that urgent deprivation of liberty applications had been made for people who needed them.
“The provider had not always made requests for restrictions to be authorised and documentation did not support decisions made.” from the report
Quality checks were not effective
seriousSome checks had lapsed, were incomplete or failed to identify the problems found during the inspection. There was no quality monitoring plan at the time of the visit.
“Checks had failed to recognise the issues we highlighted at this inspection such as unclear risk assessment, shortfalls in medicines management and ineffective records of people's capacity needs.” from the report
Communication was sometimes difficult
minorTwo people said that communication was sometimes difficult because some staff did not have English as their first language. The provider had arranged English lessons for staff.
“Two people expressed they wished some of the staff could verbally communicate better, as some of them did not have English as their first language.” from the report
- 01What changes have been made to medicines stock counts, administration records and recording of refused medicines?
- 02How are risk assessments now updated when a person's needs change, including pressure care risks?
- 03How do you check that Mental Capacity Act assessments and best-interest decisions are complete and accurate?
- 04What quality checks are now carried out for both the domiciliary care and residential services, and how are problems followed up?
- 05How are you supporting staff to communicate clearly with people who may find language difficult?
This was the first rated inspection since the provider moved premises and opened the residential service, and it covered both the domiciliary care and residential services across all five key questions. This explanation was written from the published report of 9 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 Victory Socialcare Enterprise
2 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- May 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Victory Socialcare Enterprise →
- July 2019Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
Read what inspectors found at Victory Socialcare Enterprise →
- May 2018
Registered with the Care Quality Commission on 25 May 2018.
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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13 live-in carers within about an hour of Kingston upon Hull, City of
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Most charge £1,020 to £1,350 a week. 12 can care for a couple. 8 years' experience on average.
“What truly stands out is how mindful and attentive she is to all of my medical needs, always going above and beyond to ensure I’m comfortable and well cared for.”
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