Victoria House Residential Home

Updated 7 September 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Victoria House Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Victoria House Residential Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 12 July 2022 and ended on 15 July 2022. We visited the service on 12 July 2022.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with five people who used the service and three relatives of people using the service, about their experience of the care provided. We spoke with seven members of staff including the registered manager, carers and domestic staff. We reviewed a range of records. This included three medication records and three staff recruitment records. A variety of records relating to the management of the service, including maintenance safety records, and policies and procedures were reviewed.

Updated 7 September 2022

About the service

Victoria House Residential Care Home is a residential care home providing accommodation and personal care to up to 43 people. At the time of our inspection 37 people were living at Victoria House Residential Home. The home has two floors, with bedrooms on both the ground and upper floor, with three shared communal lounges and dining rooms.

People’s experience of using this service and what we found

Systems and processes used by the provider to monitor and improve the service were in place but needed strengthening then embedding into practice. Environmental risks relating to safety checks had not been promptly carried out. Accident and incidents were monitored, however, recording of action taken required strengthening and improvement to ensure lessons were learnt.

People received medicines by staff who were suitably knowledgeable and trained. We found that medicines prescribed to thicken people’s drinks were not safely stored. When people were prescribed medicines on a 'when required basis' (PRN), guidance was available to help staff give them these medicines however they were not in line with how they had been prescribed.

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; the policies and systems in the service supported this practice.

Staff were recruited in line with regulatory requirements to ensure only suitable staff worked

in the service.

Infection prevention and control (IPC) systems were in place. The home was visibly clean; however, we identified some IPC issues which were addressed shortly after the inspection.

Staff were confident in reporting concerns internally and to external organisations. Staff felt supported by the registered manager, who they found to be approachable and visible in the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 05 March 2019).

Why we inspected

We received concerns in relation to the recruitment and selection of staff. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Victoria House Residential Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to good governance.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will continue to monitor information we receive about the service, which will help inform when we next inspect.