Victoria House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed 6 quality statements in the safe key questions and found areas of concern. The scores for these areas have been combined with the scores based on the rating from the last inspection, which was good. The rating for this key question has changed to requires improvement. We found that people did not always feel safe. Staff deployment was not managed effectively which impacted the quality and safety of people’s care. People felt rushed, receiving task-based care with people they did not know and who were not always appropriately trained. Appropriate checks during the recruitment process had not always been recorded. We made a recommendation in this area. Risks to people had not always been assessed and systems had failed to identify areas of risk after an accident had occurred. Risk from equipment had not been considered and action taken to address this issue by the provider was slow during the assessment. The service was not always clean, improvement was needed to address the infection, prevention and control practices within the service. We found a breach of regulation in relation to safe care and treatment and staffing. Systems were in place to monitor safeguarding incidents, however, not all incidents had been reported to the appropriate regulatory bodies. Mental capacity assessments and best interest decision meetings had not always taken place. People’s restrictions were not always managed appropriately and details around these restrictions were unclear. We found a breach of regulation in relation to people’s need for consent. We found people gave positive feedback regarding the management of their medicines, however, there was a high level of medication errors within the service. The provider had highlighted this concern and was working to improve this. We made a recommendation regarding the safe management of medication.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Not all people living at the service felt safe. One person told us they don't always feel safe when agency staff are supporting them. Another person told us they didn't feel safe because of other people living at the service.

The management team told us they had systems in place to record and monitor safeguarding incidents. Staff had received safeguarding training and understood their responsibilities to report any suspected abuse.

Observations showed that some people felt safe with staff they knew well, however at times there was not enough staff to respond to people or staff who were trained to support people. Restrictions were not always managed appropriately, we observed one person not able to use their wheelchair, and information regarding this restriction was unclear.

The provider had systems in place to monitor and record safeguarding’s, but these were not effective in identifying all incidents. The quality assurance lead was addressing this concern at the time of the inspection and had sent reports to CQC retrospectively. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found that MCA and best interest decisions were not always in place. Records of restriction were not clear, and staff were not able to say what the restriction was or why it was in place. The management team told us they were aware MCA and best interests had not been completed and that they had been doing training with team leaders to complete these, however prompt action had not been taken to address when restrictions were in place without MCA records.

Risks to people were not always managed and people did not always feel safe. One person told us, “I don’t feel safe sometimes when agency staff are supporting me.”

Staff we spoke with knew people and their risks. However, we could not be assured that agency staff and newly recruited staff had sufficient knowledge of people’s risk. Staff told us the deployment of staff put people at risk, as there was not always trained staff on duty who knew people well to effectively support people's needs and the risk of errors was increased. One staff member told us, "Sometimes there are people in the staff numbers who cannot move and handle, if you were doing medication and also personal care you can make mistakes."

We observed a lack of organisation in relation to people’s equipment, it was unclear which equipment belonged to each person and some slings had not been maintained to ensure they were safe to use.

Risks assessments had not always been developed to manage risks to people. Concerns were raised by inspectors on the first day of inspection but prompt action was not taken by the service to address these concerns. For example, risk in relation to bed rails had not been assessed which we raised to the manager at the time if the inspection. When we returned to continue the inspection process, these risks still had not been reviewed or mitigated. Care plans did not reflect the use of bed rails and therefore mitigation was not in place for the risk these can potentially cause. When an accident occurred and a person was injured resulting from a bed rail, action was not taken by the service to assess and manage any future risk. Risks in relation to other equipment had not always been considered. Following concerns in relation to the servicing of slings on the first day of inspection, sling servicing was carried out and several slings were found to be unsafe to use and removed from the service.

People told us they were happy with the environment and people’s bedrooms were personalised to their needs. There were different areas for people to spend their time.

The service employed a maintenance staff member to maintain the property, however part of their job role was also driving the service vehicle which sometimes impacted the amount of time they could spend on maintenance.

Some areas of the service required attention such as flooring and decoration work. Items such as chemicals and cleaning equipment were stored away safely. The building was secure to keep people safe.

Processes were not sufficient to ensure equipment used to move and handle people was safe to use. Internal health and safety checks were carried out by the maintenance staff; however, cover had not always been put in place for this check when they were not available. The systems in place were difficult to navigate and recording was often done in different areas. Fire drills had been carried out and identified areas of concerns, although some action had been taken this had been limited and had not fully addressed the areas to ensure people’s safety.

Sufficient staff were not deployed. Care was delivered in a task focused manner due to the deployment of staff which meant people did not always receive dignified care. For example, staff were supporting multiple people with eating at the same time. When discussing the care provided from agency workers, one person told us, “A lot of agencies, they don't know what they are doing. They don't know how to dress me.” Another person told us, “The agency asks me what colours to use on the sling, to me they should be trained in that area.” People told us at time’s they felt rushed. One person told us, “Some of the support workers rush you it depends on what they have on that day.” People did not always receive their funded hours of care.

Staff we spoke with confirmed there was not enough staff which impacted care delivery. One staff member told us, " We are always rushing, in everything like personal care. If you have agency in or someone who doesn’t know the service, there is at times people still in bed late morning. I try not to rush people, but then it impacts the next person as they are having to wait.” Another staff member told us, “People are often having to wait and getting frustrated with it.” Staff we spoke with raised concerns regarding the deployment of staff. They told us they were often working with staff who could not do certain tasks such as moving and handling. Of the three staff on each floor, one of the staff was allocated to administer medicines which left two people to attend to the other needs of the people. Of the 19 people living at the service 17 people required two staff to provide care resulting in delays. The quality assurance lead told us they were looking at implementing a dependency tool to assess staffing levels.

We observed delays in people getting the support they needed due to the poor deployment of staff. One person waited 50 minutes for support to get out of bed, while other people could not find a staff member to help them. Staff did not have the skills to be able to support people causing difficulties in getting the right support to people when they needed it. We observed staff trying to provide the correct care for people, but some staff members were not trained. The availability of support was directly impacted by this as people had to wait for a trained staff member to ensure safe care.

Effective systems were not in place to ensure people received their funded hours of care. We found that over a period of three weeks three people did not get there individual funded hours. This had not been addressed by the management in the service. Staff rotas did not consider that care staff were not fully trained in all areas, however these staff were included in the overall numbers to provide care. Recruitment checks were carried out; however, records were not always sufficiently robust or available in staff files. We recommend the provider review their safe recruitment processes and update their systems accordingly.

People told us cleaners come in and cleaned their rooms. However, we saw equipment was not always sufficiently cleaned for people.

Staff had received infection control training and told us they had access to personal protective equipment (PPE). Some staff raised concerns regarding the cleanliness of the service, as there was a lack of time to do cleaning and domestic staff were only in 5 days per week.

The service was not always clean. People's equipment and personal hygiene equipment was considerably dirty. For example, multiple toothbrushes and razors were seen with debris on them and people’s bedding was not always clean. One person’s toilet equipment was significantly dirty which was raised with management on the first day of the inspection. However, this had not been rectified when we visited for the second day of inspection. Improvements were required to IPC practices. For example, bins did not always have lids on. Areas of the environment required attention. For example, some areas such as kitchenette tables had edging that had chipped down to the wood compromising its effectiveness for cleaning.

The provider had cleaning rotas in place, however these had not been effective as the service was not clean. The cleaning rotas were just a tick box and did not include all areas or equipment which required cleaning. Policies were in place in relation to infection prevention and control.

People told us they were happy with the support they received with their medicines. However, there had been a lot of medicines errors at the service.

Leaders told us they had recognised the high amount of medication errors and analysis had been completed for the errors. Staff told us they were concerned that the staffing levels at times could cause them to make mistakes with medicines. One person told us, “Sometimes there is people in staff numbers who can't move and handle and if you had medicines, you are then needed to do personal care you can make mistakes.”

Processes for the safe administration and handling of medication were not always effective. We found it was unclear if instructions for medicines had always been followed by staff. For example, at times medicines that were prescribed to be given prior to food were administered with medicines to be given after food. Topical creams where not always applied. One person did not have their cream applied because they were already up, and another person had no body map in place to ensure clear direction was given for the application of the cream. As and when needed medication (PRN) did have protocols in place, but they did not always contain detail to guide staff when the medication was a variable dose. We recommend the provider review their processes in place for the safe administration of medication and update their systems accordingly. People were supported to self-medicate were appropriate.