New Victoria Nursing 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 requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was previously in breach of legal regulation in relation to people’s safe care and treatment as systems were not in place or robust enough to demonstrate risk was effectively managed. The provider remains in breach in relation to risk and the management of medicines.

The service was also previously in breach of legal regulations in relation to fit and proper persons employed. The service had made improvements in relation to safe recruitment and is no longer in breach of this regulation.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice. Some concerns noted at our last inspection were still present at this assessment.

We could not see evidence that all the concerns around safety were appropriately investigated. One person who had a deprivation of liberty safeguard (DoLS) in place to keep them safe, had managed to leave the premises unsupervised on several occasions. However, these incidents had not been investigated.

The registered manager shared raised concerns with staff in their morning meetings to raise awareness and gather feedback to drive improvements. Staff knew where and how to record incidents and felt confident the registered manager would act on raised concerns.

When 1 person had raised a concern with the operations manager we saw they had received a timely response scheduling when action would be taken.

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.

We observed the registered manager cancel 1 admission as operational issues would have impacted on the person’s admission experience. Systems were in place for the pre-admission assessments taking place before people moved into New Victoria Nursing Homes.

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.

There were appropriate policies and procedures, and staff completed safeguarding training. People were supported by staff who knew why and how to raise safeguarding concerns. Staff told us they would report concerns to the registered manager, Care Quality Commission and local authorities if they had concerns.

One person explained staff were observing him due to a fall. They commented, “I don’t feel unsafe I am too safe .” One staff member told us, “People are safe here. We make sure they are safe.”

Where people needed to be deprived of their liberty to keep them safe, the provider ensured a deprivation of liberty safeguard (DoLS) was applied for through the relevant local authority.

Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care plans were regularly reviewed and identified what support people required. Staff said care plans and risk assessments gave them enough guidance on how to support people safely. However, not all care plans had information to guide staff on how to respond to some people’s underlying health conditions. Strategies used to support people who displayed distressed behaviours were not always recorded in care plans.

Staff were trained to meet people’s needs. Observations showed staff knew how to support people and mitigate any risks by responding quickly and de-escalating situations when people were distressed. Staff were able to tell us how they would support people safely to meet their physical and mental support requirements.

The registered manager promoted a culture of empowerment and positive risk taking. People were supported to take control of their lives, make choices and experience the benefits of engaging in activities they desired. The registered manager told us, “It’s not my home, I am part of their home.” A member of staff to us, “Everyone is different, and they are all adults.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff had good knowledge of fire safety procedures, and every person had a personal emergency evacuation plan (PEEP). The purpose of a PEEP is to ensure that all people can evacuate the building safely and promptly in the event of an emergency, regardless of their level of mobility or other health conditions. Equipment was available and mostly well maintained to meet people’s needs.

There were safe recruitment practices to make sure that all staff were suitably experienced, competent and able to carry out their role.

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.

We did not have any concerns related to staffing levels or deployment. Observations showed there were appropriate staffing levels and skill mix to make sure people receive consistently safe, good quality care that met their needs. One person told us, “There always seems to be staff around.” One staff member told us staffing levels had improved.

The provider did not always assess or manage the risk of infection. There were some areas of the home that required updating or would benefit from a deep clean to promote effective management of infection prevention. This included some flooring needed replacing and the arm of 1 shower chair was ripped. Some areas of the home could benefit from a deep clean.

The provider was working towards refurbishing the home and updating bathrooms. The provider was in the process of recruiting new housekeeping staff.

New Victoria Nursing Home had a food hygiene rating of 5. This meant food hygiene standards were very good.

The provider did not always make sure that medicines safely stored. Not all medicines were checked as part of scheduled audits, and the environment where medications were stored did not met safe practice. The provider had not ensured all rooms storing medications were subject to temperature checks.

Temperature monitoring in treatment rooms is necessary to ensure the safety and effectiveness of medications and other medical supplies stored there. The provider had not followed best practice and guidance for managing controlled medications, despite this being recorded in their policy. This had not been identified in audits. Controlled drugs are drugs that are subject to high levels of regulation because of government decisions about those drugs that are especially addictive and harmful. The registered manager took immediate action and addressed these concerns.

People received their medicines as prescribed. Processes were in place to ensure people got their medicines at specific times. This included their ‘as and when required’ medicines.

We observed the nurse made the administration of medicines a positive experience, engaging in conversation. This gave people time and suitable oversight. One person when asked by the nurse if they were ok during the administration of their medicines said, “All the better for seeing you. You look beautiful.”