Archived: Victoria Hall

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. That in some cases the "good" practice had not been sustained over time as a result of gaps in quality monitoring and good governance. Therefore further time and work was needed on behalf of the provider to ensure that "good" practice found at Victoria Hall at this inspection would be sustained through robust and continuous quality monitoring and support.

Staff had received training of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS). This was also covered as part of their dementia training. 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 and DoLS in our discussions with them. We fed back to the registered manager that staff would benefit from further training. The registered manager gave reassurances staff would be given additional training specifically on the MCA and DoLS by September 2018. The registered manager also gave MCA information cards for all staff to carry on them, to refresh their knowledge, during our visit.

There were systems, processes and practices to safeguard people from situations in which they may experience abuse. Risks to people’s safety had been assessed, monitored and managed so they were supported to stay safe while their freedom was respected. In addition, the necessary provision had been made to ensure that medicines were managed safely. Suitable arrangements had been made to ensure that sufficient numbers of suitable staff were deployed in the service to support people to stay safe and meet their needs. Background checks had been completed before care staff had been appointed. People were protected by the prevention and control of infection and lessons had been learnt when things had gone wrong.

Suitable arrangements had been made to obtain consent to care and treatment in line with legislation and guidance. Care staff had been supported to deliver care in line with current best practice guidance. People enjoyed their meals and were supported to eat and drink enough to maintain a balanced diet. In addition, people had been enabled to receive coordinated and person-centred care when they used or moved between different services. As part of this people had been supported to live healthier lives by having suitable access to healthcare services so that they received on-going healthcare support. Furthermore, people had benefited from the accommodation being adapted, designed and decorated in a way that met their needs and expectations.

People were treated with kindness, respect and compassion and they were given emotional support when needed. They were also supported to express their views and be actively involved in making decisions about their care as far as possible. Confidential information was kept private.

People received personalised care that was responsive to their needs. Care staff had promoted positive outcomes for people who lived with dementia including occasions on which they became distressed. People’s concerns and complaints were listened and responded to in order to improve the quality of care. In addition, suitable provision had been made to support people at the end of their life to have a comfortable, dignified and pain-free death.

There was a positive culture in the service that was open, inclusive and focused upon achieving good outcomes for people. People benefited from there being a management framework to ensure that staff understood their responsibilities so that risks and regulatory requirements were met. The views of people who lived in the service, relatives and staff had been gathered and acted on to shape any improvements that were made. Good team work was promoted and staff were supported to speak out if they had any concerns about people not being treated in the right way. In addition, the management team worked in partnership with other agencies to support the development of joined-up care.

Victoria Hall is a residential home which is registered to provide accommodation for up to 37 people. At the time of the inspection there were 30 people living in the service.

The service had a comprehensive inspection on 28 January and 5 February 2015 when we found four breaches of the regulations. These concerned staff recruitment, recording in care records, issues regarding the deprivation of people’s liberties and assessment of their mental capacity. The provider wrote and told us what they would do to meet the legal requirements in relation to the breaches. We inspected the service again on 9 August 2016 and found the service still required improvements in three out of the five key areas we inspect against with one breach around failure to display their rating. This had been addressed in our most recent inspection.

We undertook a further unannounced comprehensive inspection on 11 and 13 July 2017 and found a number of concerns and breaches of the regulations. We had some immediate concerns about the premises, fire safety and events surrounding accidents. We brought this to the immediate attention of the manager to address. We then visited again with a fire officer from the local fire service. Some immediate remedial actions were taken but we still had concerns and wrote to the provider, telling them what concerns we had. We sought assurances from them that these would be addressed to ensure people were safe at the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were not adequately protected from risks to their safety. This was because risks were poorly managed and there was no evidence of lessons learnt in which the service changed their practices in light of an incident or accident. Our particular concerns were around fire safety, the maintenance of equipment and managing falls. We also had some concerns about poor infection control practices. We later received assurances from the manager that they had taken actions to address the safety issues which we found.

Staffing levels were not always adequately maintained across the day and additional staff were not available at busier times of the day. The provider did have a dependency tool but we found this unreliable in determining how many staff they needed to meet people’s needs. This meant we could not be assured staffing levels were always adequate.

Staff were trained and assessed as competent to administer medications. However we found some gaps in record keeping which had not been identified by the service. This meant the medication audits were not as robust as we would expect.

The provider’s recruitment process ensured that only staff that had been deemed suitable to work with people at the home were employed.

We were not assured people were always eating and drinking sufficiently. There were no adequate systems or ways of monitoring of this. We were not confident that people had their health care needs adequately and monitored and met. The service did not have robust records which would enable us to draw conclusions as to how people’s health and care needs were being met.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found that the registered manager understood legislation in relation to this. They had made a number of DoLS when required. The registered manager told us that applications had been submitted to the relevant local authorities and were awaiting the outcome of these.

Staff knew people well and were responsive to their needs. On the whole we saw staff interactions and practices were positive. However, we observed care that was not individualised or personalised.

Care records telling staff what people’s needs were and how they should meet these needs were in place. However, these records contained a lot of generic information. They were not personal to individuals. Not all the information reflected people’s current needs and we found records were not accessible. Records were kept in a number of different places and there was not always an accurate record of people’s care needs.

There was a programme of activities but the service did not demonstrate that activities hours were sufficient to meet the social needs of people or give them sufficient opportunity to engage in meaningful activity.

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The service had a complaints procedure and complaints were responded to quickly. However we found that the responses did not indicate an open culture which welcomed feedback and helped the service to improve.

The manager was overseeing two services and we felt this contributed to them not having a clear overview of risk within this service. There was poor support from the provider and the monitoring of the service was not adequate. The analysis and overview of accidents and incidents was completed by staff employed by the company but not the manager. Therefore the manager was not able to respond to these incidents and take the appropriate action to prevent incidents from happening again.

Consultation with people using the service and other stake holders was poor and it was not clear how feedback helped to improve the service.

We found a number of breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report

At our last comprehensive inspection on 28 January and 5 February 2015 we found four breaches of the regulations. These concerned staff recruitment, recording in care records, issues regarding the deprivation of people’s liberty and assessment of their mental capacity. The provider wrote and told us what they would do to meet the legal requirements in relation to the breaches.

We undertook this unannounced comprehensive inspection on 9 August 2016 and found the provider had followed their plan and had made the necessary improvements.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe living at the home. Staff were knowledgeable about the procedures to ensure that people were protected from harm. Staff were also aware of whistleblowing procedures and would have no hesitation in reporting any concerns. Prescribed medicines were safely administered to people.

There were sufficient numbers of staff employed at the home. However, it was noted that staff had little time to socialise and provide activities for people. The provider’s recruitment process ensured that only staff that had been deemed suitable to work with people at the home were employed after all pre-employment checks had been satisfactorily completed.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found that the registered manager and all staff were knowledgeable about when a request for a DoLS would be required. The registered manager told us that applications had been submitted to the relevant local authority’s and were awaiting the outcome of these. The registered manager was aware of who to contact should they need to submit an application.

Staff respected and maintained people’s privacy at all times. People were provided with care and support as required and people did not have to wait for long periods of time before having their care needs met. People’s dignity was respected.

People’s assessed care and support needs were planned and met by staff who had a good understanding of how and when to provide people’s care whilst respecting their independence. Care records were up to date and provided staff with current guidelines on how to meet people’s needs. Risk assessments were in place to ensure that people were supported with potential care and health risks.

People were supported to access a range of health care professionals. People were consistently supported with their health care needs in a timely manner.

People were provided with a varied menu and had a range of healthy options at meal times. There was a sufficient quantity of food and drinks available at all times.

People’s care was provided by staff in a kind, caring and compassionate way. There were few opportunities for social engagement or for people to develop and engage in hobbies and interests.

The home had a complaints procedure which all staff were aware of. People had access to information on how to make a complaint and were confident their concerns would be acted on. Action was taken to address people’s concerns and prevent any potential for recurrence.

People were provided with ways that they could comment on the quality of their care. This included regular contact with the provider, registered manager, completing annual quality assurance surveys and attending meetings.

We found one breach of the Health and Social Care Act (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report