Victoria Court Private Rest Home

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm

This is the first assessment for this service under a new provider. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. The registered manager had systems in place to promote openness and listen to concerns. Incidents, accidents, complaints and safety events were investigated and actions taken to share learning and keep people safe. The registered manager took steps to share learning, and to continually identify and embed good practice with staff.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Before people came to live at the service the registered manager completed a full assessment of their needs to ensure they could be met by the service. People and their relatives had an opportunity to visit the service before they moved in to see if it was a place they would like to live. The registered manager liaised with other healthcare professionals to ensure peoples healthcare needs continued to be supported. A healthcare professional told us, “This service has been very good at continuing to support [person name] on-going healthcare needs.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. People told us they felt safe living at the service, one person said, “I feel safe living here, it is a safe place to live.” Another person said, “When I first came to live here, I was anxious and use to cry a lot, but now I love it here I don’t want to go home anymore.”

Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff had received training in safeguarding and knew how to raise concerns either with the provider or externally. One member of staff said, “I know how to raise safeguarding concerns and will keep escalating them until they get resolved. The residents here are safe.” The registered manager shared concerns promptly and appropriately and worked with the local authority to investigate these to keep people safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. There was a balanced approach to risks to ensure people could continue to enjoy doing things that mattered to them whilst minimising the risk of harm to them. Risk assessments in place were person centred and supported the mitigation of harm to people. Risks were discussed with people and regularly reviewed to ensure they remained relevant and up to date.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The registered manager completed environmental checks to ensure the environment remained safe. This included checking water temperatures and having up to date certificates in place for gas, electrical equipment, lifting equipment and the service lift. In addition, pest control and waste removal services were in place. A recent fire inspection assessment had been completed.

Since the new provider had taken over the service, they had undertaken a refurbishment program which was continuing to refresh and update the service for people living there.

The service had an on-site maintenance person who was supporting with the refurbishment. The registered manager was trained to deliver fire safety training to staff and undertook regular fire training and practice scenarios. People had personal evacuation plans (PEEPS) and staff had the appropriate equipment available should they need to support people with an evacuation.

There was access to outside space with a garden which people told us they enjoyed using. One person said, “We have a lovely garden we can sit out in when the weather is nice.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. People told us there was enough staff working at the service to support them. One person said, “The staff are very nice here, always around if you need them.”

The registered manager completed employment checks before staff began working at the service. This including obtaining references, right to work and up to date disclosure and barring checks (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer and help employers make safer recruitment decisions.

Staff completed an induction to the service and completed a probationary period. Training was supported and this included face to face training to develop staff skills in specific areas of care including moving and handling. All staff were supported with 1:1 supervision at regular intervals and observations were completed of their work to ensure they were maintaining standards.

The registered manager held regular meetings with staff to share information and discuss important issues to keep staff up to date.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff had received training in infection prevention control. There was personal protection equipment (PPE) available for staff to use when needed. The registered manager employed dedicate cleaning staff who had systems in place to maintain cleanliness at the service. Cleaners also had a schedule in place to complete fuller environmental cleans on a regular basis.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found protocols missing in some records for medicines prescribed as when required (PRN). Protocols are important as they help staff understand when it is appropriate to offer PRN medicines. The registered manager took steps to immediately rectify this and shared with us protocols they would be using moving forward for all people on PRN medicines.

We found some topical creams had not been dated when opened. This meant we could not be assured these creams were being used within the manufacturer’s recommended time-frame once opened for optimal effectiveness. Following the inspection the registered manager raised this with staff and has added this check to their medication audit.

Staff had received training in managing medicines and had their competency checked. A member of staff told us, “I had my medicines training, and my manager carried out observations and checked my competency.” Staff we spoke to were knowledgeable about the people in the service and their medicines needs.

People told us staff provided their medicines to them when they needed them. One person said, “The staff give me my medicines so that I do not forget them.”