Archived: The Victory Re-ablement Unit

The home had a registered manager. 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 of the Health and Social Care Act and associated Regulations about how the service is run.

At our last inspection we rated the service good. We found a breach of Regulation 18 of the Health and Social Care Act (regulated Activities 2008) 2014 Staffing. This was because the service did not have robust procedures in place regarding recruitment. At this inspection we found improvements had been made and the provider was no longer in breach of this regulation.

People told us they received care and support that was very good and was delivered in a way that met their needs and preferences.

People were supported to regain their independence, they had comprehensive goals set and treatment plans in place which enabled them to return home.

There were enough skilled staff to meet people’s needs and staff focused on providing people with individualised support that was provided in a caring and professional manner.

Medicines were managed safely and were administered by trained staff.

The registered manager and staff understood their responsibilities to comply with the requirements of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLs). People were encouraged to make choices about their day to day care and plans for the future.

People had enough to eat and drink and were complimentary about the food on offer.

The environment was clean, welcoming and met the needs of the people who used it. Regular health and safety checks were carried out.

There were systems in place that monitored the quality and the safety of the service provided. Records were thorough, comprehensive and regularly reviewed.

Feedback was encouraged from people, staff and other health professionals and the registered manager was keen to drive improvement in the service.

People and staff said the management of the service was very good.

Further information is in the detailed findings below.

During the inspection 18 people were being accommodated. There was a new admission later in the day and one room had temporarily been out of use due to an issue regarding a fire door.

The service had a registered manager. 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.

The service was last inspected when the service was at their old address on July 2014 and at this time the service was found to be compliant with the regulations looked at.

Staff understood the principle of keeping people safe and appropriate safeguarding referrals had been made to ensure people were kept safe. Assessments including risk assessments had been completed as part of the care planning process. The multi-disciplinary team met the needs of people, with the service having enough staff to meet the needs of people. There was a training programme which staff could access. Recruitment checks had not been updated as staff had transferred or moved from closing services of the provider. Medicines were administered and stored safely.

Staff had knowledge of the Mental Capacity Act and people’s records demonstrated people’s capacity to make specific decisions had been assessed. People enjoyed their meals and were offered a choice at meal times. People were supported to access a range of health and social care professionals.

People had their needs planned and met in a personalised way, which reflected their choices and preferences had been considered. People felt confident they could make a complaint and it would be responded to. Complaints were logged and there were recordings of investigations into complaints.

People felt the staff were caring, kind and compassionate. The home had an open culture where staff felt if they raised concerns they would be listened to. Staff felt supported by the registered manager and were clear about their roles and the values of the service. Records were accurately maintained and there was an effective quality audit process.

We found one breach of the Health and Social Care Act 2008 (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.