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Archived: Victoria Hall Good

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Inspection Summary


Overall summary & rating

Good

Updated 21 June 2018

This inspection took place on 30 April 2018 and was unannounced. We returned on the 01 May 2018 to complete the inspection. The management team was given notice of the second date, as we needed to spend specific time with them to discuss aspects of the inspection and to gather further information.

Victoria Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

Victoria Hall is registered to accommodate 37 people in one adapted building. There were 20 people living in the service at the time of our inspection visit.

There was a registered manager in post. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated regulations.

At the last inspection on 11 and 13 July 2017 the service was rated 'Inadequate.' The report was published in October 2017. At that inspection we identified five regulatory breaches’ of the Health and Social Care Act 2008 (Regulated Activities) 2014. This was due to the registered manager not fully assessing the risk to the health and safety of people using the service. The registered manager was not able to demonstrate that they had sufficient numbers of staffing at all times to ensure people's physical and social needs were adequately met. People were not being adequately supported to have enough to eat and drink and there was poor monitoring of this. The registered manager was unable to demonstrate through her records how they provided individualised care based on the accurate assessment of people's needs. Systems and processes were not sufficiently robust and were not identifying areas requiring improvement.

We also found the service was in breach of one regulation of the Care Quality Commission (Registration) Regulations 2009. This was due to the service failing to notify us of significant incidents in a timely way.

Since our last inspection, we have continued to engage with the registered manager. We required the registered manager to complete an action plan to show what they would do and by when to improve the key questions is the service safe, effective, caring, responsive and well-led to at least good.

At this inspection in April and May 2018, we confirmed that the registered manager and provider had taken sufficient action to address previous concerns and comply with required standards. As a result, at this inspection we found significant improvements had been made and maintained, resulting in the overall rating of the service being changed to, ‘Good’.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

At this inspection for the key question is the service ‘well led’ we have rated it as ‘Requires Improvement’. We found although there were significant improvements in the care planning, time was still needed to ensure they were accurate and fully completed. The provider agreed with our findings and gave a target of May 2018 for completion.

Although at this inspection quality checks had been completed to ensure people benefited from the service being able to quickly put problems right and to innovate so that people consistently received safe care, the previous inspections published in June 2015, September 2016 and November 2017 had identified variable quality and compliance issues.

Inspection areas

Safe

Good

Updated 21 June 2018

The service was safe.

Care staff knew how to keep people safe from the risk of abuse.

People had been supported to avoid preventable accidents and untoward events.

Medicines were safely managed.

Suitable arrangements had been made to ensure that sufficient numbers of suitable staff were employed to support people.

People were protected by the prevention and control of infection and lessons had been learnt when things had gone wrong.

Effective

Good

Updated 21 June 2018

The service was effective.

Staff had received an overview of the Mental Capacity Act (MCA) as part of their dementia training and our observations confirmed staff promoted choice and acted in accordance with people's wishes. However, not all staff demonstrated a clear knowledge of the MCA or with the Deprivation of Liberty Safeguards (DoLS)

People enjoyed their meals and were helped to eat and drink enough to maintain a balanced diet.

People received coordinated care when they used different services and they had received on-going healthcare support.

The accommodation was adapted, designed and decorated to meet people’s needs and expectations.

Caring

Good

Updated 21 June 2018

The service was caring.

People were treated with kindness, respect and compassion and they were given emotional support when needed.

People were supported to express their views and be actively involved in making decisions about their care

People's privacy, dignity and independence were respected and promoted.

Confidential information was kept private.

Responsive

Good

Updated 21 June 2018

The service was responsive.

People received personalised care that was responsive to their needs.

Positive outcomes were promoted for people who lived with dementia.

People told us that they were offered the opportunity to take part in a range of social activities.

People’s concerns and complaints were listened and responded to in order to improve the quality of care.

Suitable provision had been made to support people at the end of their life to have a comfortable, dignified and pain-free death.

Well-led

Requires improvement

Updated 21 June 2018

The service was not always well led.

Care plans were in varying stages of completion. This resulted in records not always being accurate or complete.

Victoria Hall demonstrated most of the characteristics of good leadership. However further time and work is required to ensure that their systems for monitoring and improving services are embedded and to demonstrate that "good" practice can be sustained over time.

There was an open culture and people benefited from staff understanding their responsibilities so that risks and regulatory requirements were met.

People who used the service, their relatives and staff were engaged and involved in making improvements.

There were suitable arrangements to enable the service to learn, innovate and maintain its sustainability.

Quality checks had been completed and the service worked in partnership with other agencies.