Victoria Street

Updated 12 March 2022

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to the COVID-19 pandemic we are looking at how services manage infection control and visiting arrangements. This was a targeted inspection looking at the infection prevention and control measures the provider had in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

This inspection took place on 27 January 2022 and was announced. We gave the service 24 hours’ notice of the inspection.

Updated 12 March 2022

The inspection took place on 20 August 2018 and was announced.

Victoria Street 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 (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

At the time of this inspection there was no registered manager in post. We were supported by the acting manager who advised us they would be applying to register with CQC within the next month. 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.

At the last inspection on 22 December 2017, we rated the service requires improvement overall and identified two breaches of regulation relating to staffing and the governance of the service. This was because the provider had failed to follow their own policies and procedures to ensure staff were supported through regular training, competency checks, supervision and appraisal of their performance. The provider did not have an effective system in place to assess, monitor and improve the quality and safety of the service provided. Quality assurance systems and audits in place were ineffective.

Following the inspection, the provider submitted an action plan telling us what action they would take to meet the breaches in regulation. At this inspection, we checked and found the provider had completed all the actions. The provider had a schedule in place to ensure all policies and procedures were updated by December 2018, during the inspection we evidenced that some of these had been reviewed and updated. The provider had made sufficient improvements to meet the breaches of regulation 18; Staffing and regulation 17; Good governance.

Staff were receiving regular supervisions and appraisals in line with the providers policies and procedures and future dates had been scheduled.

Staff training had been improved as the provider had sourced further training that staff could complete at their own pace. Records showed that staff had completed safeguarding training and various other courses to further their knowledge and skills. This showed us that the provider was committed to investing in supporting staff to maintain and develop their skills and expertise to encourage better outcomes for people.

The providers’ policies and procedures were being reviewed across the organisation at the time of this inspection. We could see that several policies had been reviewed and updated to reflect current legislation. The area manager told us this was work in progress and as stated in their action plan would be completed by December 2018. An internal audit matrix had been introduced and each area audited had a separate file with details of the audit, areas identified for improvement and the date these were to be completed. A continuous improvement plan was in place to monitor and drive improvements in the service. Records showed external auditors visited every three months to oversee the running and management of the service.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

Staff received medicines training annually and competency checks to ensure the safe administration, storage and disposal of medicines.

Staff could tell us about the different signs and types of abuse and knew how to report any concerns in relation to harm and abuse. Staff had received training in safeguarding adults from harm or abuse.

The provider had systems and processes in place to ensure the environment was safe for people and regularly maintained. Risks to people had been identified and appropriate measures put in place to mitigate them.

Staff worked as a team to ensure shifts were covered by consistent staff that knew people’s needs well. The provider had robust recruitment checks in place to ensure people were of a suitable character to work in a care home setting.

The provider had updated their data protection policies to include the recent changes in legislation. Confidentiality policies had been revised and people, staff and their relatives informed about any changes in terms of how their personal data would be stored and used.

The manager understood their responsibilities as part of their CQC registration and could tell us in which circumstances they were required to inform us of significant events that happen in the service.

Records showed that staff supported people to manage and attend appointments in relation to their health and well-being.

Staff knew the importance of treating people with dignity and respecting their wishes. Observations showed staff knew people extremely well and offered person centred choices and promoted people’s independence.

Staff had a good awareness of people’s nutritional and hydration needs. People were encouraged to make meal choices and had support to prepare meals when needed.

Staff spoke positively about their experiences outside the service when they took people to enjoy various activities of their choice. The provider encouraged sensory activities which stimulated people in a positive way and were constantly looking at ways to improve people’s experiences.

People felt familiar with their community. Staff created a safe environment where people could walk to the shops and feel comfortable in the presence of other people.

Staff adhered to the Mental Capacity Act (MCA) and asked for people’s consent before carrying out care and support tasks. For people who lacked capacity to make decisions for themselves, best interest decisions were arranged with health professionals and relatives input.