Victoria Care 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. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People at the home had been experiencing a high number of falls, the registered manager took action to reduce this number by providing falls specific training for staff and analysing falls information to identify trends. Falls champions were appointed and monthly falls meetings took place to learn from incidents from the previous month. They repositioned staff to make it easier for them to observe people that were at higher risk of falls.

Where mistakes had been made relevant professionals were informed, including the local authority and CQC, as appropriate. The provider understood their responsibility under the duty of candor to inform relevant individuals when errors were made. Relatives told us the home contacted them if an incident arose.

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.

The providers electronic care planning system included digital information packs which were readily available detailing people’s needs in case of emergency transfers to hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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. The provider shared concerns quickly and appropriately.

People we spoke with told us they felt safe living in the home. Staff were able to clearly describe the process of identifying and reporting any potential abuse. Staff said, “If I witnessed any abuse, or something concerned me, I would report it straight away to my manager. If I didn't feel able to do that, I would report it to management above. If I didn't think action was taken, I'd report it to the Safeguarding team, the contact details are in reception.”

Staff were trained in safeguarding and the Mental Capacity Act to enable them to understand how to protect people’s rights.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Whilst most risks had been assessed and guidance put in place for staff, we did identify some areas that were not, such as alcohol misuse. We fed these back to the provider who actioned this promptly.The home kept a clinical risk register to record and monitor specific risks to individuals.

People were supported to transfer from bed into mobility equipment such as hoists and wheelchairs safely. Family members told us, “They’re very gentle with handling her.” and “I see them [staff] hoist her to put her in a chair while they clean her and the room. It’s all done safely.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We observed the environment to be, in areas, in need of refurbishment and maintenance. There was also the risk of legionella due to a build-up of limescale on people’s taps. We raised this with the registered manager who instructed an audit and replacement of taps as required.

We noted that doors to areas that could cause harm to people were left open, for example a cupboard containing tools and the laundry. The registered manager immediately took action to address and put up signs as reminders to staff.

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.

The provider used an electronic staffing tool based on people’s individual needs to calculate required staffing levels to keep people safe. People told us, and we observed, there were times communal lounges were left unattended for periods of time. People felt staffing levels were lower at weekends, although there was no direct impact on people evidenced, and people said if they use their call bell staff “usually come straight away”.

We saw evidence that staff were recruited safely and trained appropriately to be enable them to safely meet people’s needs.

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.

Rota’s showed that there was adequate domestic cover to ensure the home was kept clean to help with infection prevention. Audits were carried out to ensure staff were working in line with best practice, an action plan from these was created and the IPC (infection prevention control) champion was responsible for ensuring the actions were completed.

People were mostly positive about the cleanliness in the home. A family member told us, “The place is always spotless, and her washing gets done daily.

Staff were trained in infection control; a policy was in place and care staff were seen to be wearing appropriate PPE (Personal protective equipment) whilst supporting people. We had feedback from families who told us this was not always the case and staff did not always wear PPE. We did note that not all kitchen staff were wearing appropriate PPE whilst cooking, we fed this back to the registered manager who took prompt action to address this.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We found that some gaps within medicine administration records (MARs), however the provider was implementing a new electronic system which would flag this to staff. There were also some issues with stock counts however again the new system would rectify this.

We found that creams and liquids were not always dated on opening on some units and some were stored in people’s rooms. This placed people at risk of receiving support with creams that had reduced effectiveness.

We noted that some people who took medicines “as and when” required, there were no protocols in place or if they were in place they lacked sufficient details. The registered manager promptly put these in place once we fed this back to them. The implemented documentation was personalised and contained information such as when to escalate to a GP or what de-escalation techniques to use prior to administering medicines for agitation.

Some people had their medicines covertly; this means they are not always aware that theywere being supported totakemedicine tomaintaintheir health and wellbeing. We saw evidence of appropriate authorisation and direction in place.

All staff had good knowledge on time critical medicines, and these were given generally on time; to support this staff set a timer for any time critical medicines. All staff had good knowledge how certain medicines, such as blood thinners, would impact people who experienced a fall and knew what action they would take.