The inspection team who carried out this inspection was made up of two inspectors and an expert by experience. We spoke with the deputy manager, two members of staff and a quality assurance manager from the provider group. The registered manager was on leave at the time of our inspection. We also spoke with a visiting healthcare professional to the home. Speaking with these people helped answer our five questions. Is the service safe? Is the service effective? Is the service caring? Is the service responsive and is the service well led? Below is a summary of what we found. This summary is based on our observations and evidence we found during the inspection. We were able to speak with eleven people who lived at the home and five relatives. Most of the people we spoke with were able to tell us about their experiences of what it was like living at Victoria Manor.
In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at the time of our inspection. Their name appears because they were still the manager on our register at the time.
If you want to see the evidence that supports our summary, please read the full report.
Is the service safe?
People confirmed they felt safe at the home. One person told us, "Yes, because I've had no falls since I've been here." They explained this was because assistance was available if they wanted to move around. Another told us, "I feel very safe."
We found staff had completed the required training to support them in delivering care in a safe way.
We checked whether people's medicines were being managed safely. This included checking if arrangements were in place to protect people against the risks associated with the unsafe management of medication. We found that areas of medicine management required further improvement. Arrangements in place for obtaining medicines did not ensure that people's medicines were always available for them. This meant people's health could be harmed.
We found complaints, accidents and incidents were not always being recorded. The lack of such records meant accurate monitoring of patterns of complaints, accidents and incidents could not take place to reduce the risks of them reoccurring.
Staff had received training in the Mental Capacity Act and the Deprivation of Liberty Safeguards. This training would support staff in understanding when an application should be made and how to submit one.
Is the service effective?
People's health and care needs were assessed and people had been involved in planning the care they received. Most people we spoke with were aware of the contents of their care plans. One person told us, 'Yes, it's very good. Seen and understood.' Another person told us, 'Yes, and I'm happy with the contents.' One person said, "Yes, and I'm sure I could access a copy. And it is reviewed regularly."
One person had not received their prescribed medication to support their mental health. The person's behaviours were having a negative impact on other people who used the service. There was a lack to information to support staff in managing these behaviours.
Victoria Manor provides a service to people living with dementia. We found there was no sensory or other similar material to provide stimulation and interest or to promote engagement for those people with dementia care needs.
Is the service caring?
During our visit we observed staff speaking to people and their relatives in a friendly manner. People we spoke with told us they were happy with the care and support they received. People felt they were treated as individuals and staff knew their names and a little about their backgrounds. Comments included:
"Very much so, they're very friendly. Even if you need something from the supermarket, they'll get it."
"Yes, they all know my first name."
"They come across and chat to X. There's kindness and connectivity."
Is the service responsive?
People we spoke with felt they could rely on staff responding promptly when they were called. One person told us, "If I get up at night they come quickly. There's an alarm under my mat." Another person said, "Quickly. And my family is advised if I'm not well."
One person responded, "Very quick. They're just around the corner."
Care records we looked at confirmed people were referred to other healthcare service providers when a need was identified. A healthcare professional visiting the home described the staff as 'very co-operative'.
Staff completed a 'resident transfer form' if a person required emergency medical treatment. The sheet included all the important information the hospital would need to help them understand the medical and psychological needs of the person.
Is the service well-led?
Quality assurance processes were in place to ensure people received a good quality service. There were regular meetings for people and their relatives. An annual quality survey was conducted by an independent research agency on behalf of the provider. The results were analysed to identify any areas where improvement was required.
Staff told us they were supported within their job roles through a system of staff supervision and annual appraisals. One member of staff described support from the management team as "good, they give good support". They went on to say, "There is good support from the staff as well, we work as a team."
The service had an emergency contingency plan in place. This ensured people would have continuity of care if the home became uninhabitable for any period of time.