Victoria Road

Updated 20 August 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector. We visited the home on one day and made telephone calls and gathered additional evidence over two days.

Service and service type

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

The service did not have a manager registered with the Care Quality Commission at the time of inspection. The manager submitted an application to become registered with the Care Quality Commission prior to the inspection. They have since successfully become the registered manager.

This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with one person who used the service about their experience of the care provided. We spoke with seven members of staff including the nominated individual, director of quality, registered manager, project manager, senior care workers and care workers.

We reviewed a range of records. This included three people’s care records and one person’s medicine records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 20 August 2021

About the service

Victoria Road is a residential care home providing accommodation and personal care for up to four people with a physical disability, learning disability, autism, sensory impairment or a mental health diagnosis. Three people were receiving support at the time of the inspection. The home is made up of four self-contained flats, an office and a shared garden.

People’s experience of using this service and what we found

The providers systems and processes had not identified all the concerns we found on inspection. This included concerns regarding COVID-19 practices, medicines, assessing risks, recruitment, management of complaints and incident management.

We were only somewhat assured by the provider’s infection prevention control measure to prevent the spread of COVID-19. People’s known and historical risks were not consistently recorded in their care plans. Medicines were not always managed safely.

People’s communication needs were identified in their care plans but there were some missed opportunities to explore why people expressed certain emotions and how staff could best support them.

Incident forms did not contain enough detail as to why staff had administered people’s ‘as needed’ medicines. Incident forms for one person contained details of potential restrictive practices.

People were not always supported to have maximum choice and control of their lives however staff supported them in the least restrictive way possible and in their best interests; The policies and systems in the service did not always support this practice.

People’s life histories, wishes and preferences were not consistently recorded. People told us they expressed their views but there was no record of how they were listened to and supported. People’s wants, needs and goals were not consistently recorded.

Staff had a good knowledge of what safeguarding meant in their role. People had choice and flexibility about their privacy. Staff told us they supported and encouraged people to be independent.

The registered manager was open and honest and acknowledged improvements were needed to ensure people were receiving good quality person centred care. The registered manager had lots of ideas of how to improve the service to benefit the people living there. Staff told us they felt confident in the management team and they felt able to raise concerns and share ideas.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting some of the underpinning principles of right support, right care, right culture. The model of care did not always maximise people’s choice, control and independence. Care was not always person-centred. The Ethos, values, attitudes and behaviours of leaders and care staff was positive, and the registered manager was able to talk about what measures they were putting in place to ensure people using the service led confident, inclusive and empowered lives.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for the service under the previous provider was good, published on 18 January 2019.

Why we inspected

This was a planned inspection of a newly registered service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvement. Please see all areas of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, safeguarding people from abuse and governance at this inspection.

Please see the action we have told the provider to take at the end of this report. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.