We carried out an inspection of Victoria Park on 17 and 22 May 2017. The inspection was unannounced.Victoria Park provides accommodation with personal care for up to 32 people. There were 28 people living in the home at the time of our inspection. Some people were living with dementia.
A registered manager was 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.
The service was last inspected on 28 July 2016 when we found breaches in the regulations in relation to supporting people who lacked capacity to make decisions, providing safe care and treatment to people and good governance. We asked the provider to take the necessary steps to ensure the required improvements were made. At this visit we found actions had been taken which had resulted in some improvements. This was in regards to working with people who lacked capacity and the management (good governance) of the home. However, we identified further actions were required to ensure the home consistently operated safely and effectively.
During our last inspection we found medicines were not consistently managed or administered safely which meant people did not always receive their medicines as prescribed. Following the inspection, we continued to receive reports in relation to concerns about medicine management. During this inspection we found continued concerns with medicine management, this was in relation to administration, storage and recording of medicines. The provider had not ensured sufficient action had been taken to ensure medicine management was safe.
During our last inspection we found improvements were needed to ensure staff understood the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards and the need to ensure people consented to care. During this inspection we found the necessary improvements had been made. The provider had identified people whose care plans contained some restrictions to their liberty and had submitted the appropriate applications to the authorising authority in accordance with the legislation. Staff understood the principles of the Mental Capacity Act 2005 and sought people's consent before supporting them.
Overall, staff knew about risks associated with people’s care and knew what they needed to do to keep people safe. However, it was not clear from records that risks were managed consistently to keep people safe. Accidents and incidents were recorded and the process to report these to CQC had improved. These were reviewed each month by the provider so they could identify any actions required to reduce the risk of them happening again.
People told us they felt safe living at the home and there were usually enough staff available to meet their needs. People felt that most of the time, staff knew how to support them and staff told us they had received the training they needed to effectively meet people’s needs.
Recruitment checks were carried out prior to staff starting work at the home to make sure they were suitable to work with people who lived there.
New staff received an induction to the home when they started their employment and received training based on the Care Certificate, to develop their skills to care for people effectively. There was a training plan in place to ensure all staff completed the required training, some staff were due to update their training.
Most people said they enjoyed the food and there were choices of drinks and meals provided. We could not be sure that people who needed to have their food and drink monitored, always had enough to eat and drink, as records were not always completed correctly. People were referred to health professionals to ensure their health and well-being was maintained and people told us they could access the doctor when they needed to.
People and their families were overall positive about the care provided by staff. Staff members demonstrated a caring approach towards people but some practices related to people’s privacy and dignity were in need of improvement.
Staff supported people to make choices and some staff knew the people they cared for well. People were encouraged to maintain relationships important to them and staff recognised the importance of promoting people’s independence.
Care records were sometimes not clear or sufficiently personalised to ensure people’s preferences and needs were met. However, staff spoken with had a good understanding of people’s preferences. There were staff employed to organise social activities and to provide opportunities for engagement and stimulation for people. Work was ongoing to ensure activities were suited to all people in the home. We observed people who participated in social activities enjoyed them.
The provider had systems and processes to monitor the quality of care and services people received although sometimes these had not been effective in ensuring actions for improvements identified were effectively carried out. People and their relatives had the opportunity to get together formally to feedback any issues or concerns. People knew how to make a complaint if they wished to do so.
Staff were positive about working at the home and felt the management team were approachable if they had any concerns. The registered manager had been in post for eight months at the time of our visit and was supported by the provider’s management team to drive improvement at the home.
We found a continued 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.