This inspection took place on 22 February 2018 and was unannounced.

Victoria Care Home 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.

Victoria Care Home accommodates up to 53 people in one purpose built building divided in to two units. The ground floor accommodates people that require nursing care. The first floor specialises in providing care to people living with dementia and related conditions. On the day of the inspection 45 people were living at the home. There are 46 single rooms and six double rooms. It is situated in Rainford, St.Helens.

The service has 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.

At the last inspection on 6 October 2016 we found that there were a number of improvements needed in relation to safe care and treatment, privacy and dignity and good governance. These were breaches of Regulation 10, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Effective, Caring and Well-led to at least good. The provider sent us an action plan that specified how they would meet the requirements of the identified breaches. During this inspection we found all the required improvements had been made.

This inspection was done to check that improvements had been made to meet the legal requirements planned by the registered provider after our comprehensive inspection on 6 October 2016. The team of two inspectors and an expert by experience inspected the service against all of the five questions we ask about services: Is the service Safe, Effective, Caring, Responsive and Well Led? We found that the registered provider was meeting all of the legal requirements.

Improvements had been made that related to people being treated with dignity and respect by staff. We observed people being treated with dignity and their privacy was respected. Many positive interactions between staff and people living at the home were observed throughout the inspection visit.

Improvements had been made to people's dining experience. People spoke positively about the food and told us they were always offered choices of food and drink. We observed the dining room experience and found it to be positive. Staff demonstrated good interaction and offered appropriate support when required.

Improvements had been made with the consistent completion of records that related to people's safe care and treatment. People that required regular well-being checks, repositioning and nutrition and hydration monitoring had records in place that were fully completed.

Improvements had been made to the governance systems undertaken by the registered provider at the home. Regular audits were undertaken and areas for development and improvement were identified and actioned.

Safe and robust recruitment practices were in place and sufficient staff were employed to meet the assessed needs of the people living at the home. All staff had undertaken a comprehensive induction and completed the mandatory training required for their roles. Supervision and appraisals took place regularly. Staff attended team meeting and shift handovers.

People were assessed before they moved in to the home and this information was used to produce detailed risk assessments and person centred care plans. People's choices were included and their independence was promoted where possible. All documents were

This inspection took place on 6 October 2016 and was unannounced.

We previously carried out an unannounced comprehensive inspection of this service on 30 June 2016. After that inspection we received concerns in relation to people experiencing weight loss while living at the service. Concerns were also raised regarding the communication between staff and people living with dementia. As a result we undertook a focused inspection to look into these concerns. This report only covers our findings in relation to those topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Victoria Care Home on our website at www.cqc.org.uk”

The service had an overall rating of good at the last inspection, however the ‘well led’ domain was rated as requires improvement.

Victoria Care Home is located in the village of Rainford, St. Helens, providing nursing care and support for up to 53 residents. The service which is part of the Four Seasons Health Care Group, is a modern, purpose built facility with 46 single bedrooms, and six double bedrooms, set over two floors. The ground floor, Alexander unit accommodates people who require nursing care. The Edward unit on the first floor, accommodates people who require care and support with dementia and related conditions.

A registered manager was in post; however was on extended leave until January 2017. A temporary manager was in post to cover the period of absence. 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.

During this inspection on 6 October 2016 we found breaches of the Health and Social care Act 2008 (Regulated Activities) 2014.

During the mealtime experience upstairs we found people were not offered choice from the menu. Two people were being fed at the same time by one member of staff who offered very little positive interaction whilst carrying out this task. People told us they did not enjoy the meals. People were not offered a choice of sandwich fillings, were not told the flavour of the soup or asked whether they would like white or brown bread. The mealtime experience was not managed in a way that promoted a pleasant dining experience for people, while maximising their choice and control. People's perception and understanding of how to access food and drink was influenced by their level of independence.

We found essential records for the monitoring of nutrition and hydration were not fully completed which meant that staff could not be sure people had eaten enough food or drank enough fluids. This left people at risk of dehydration and malnutrition.

Staff on the first floor consistently demonstrated poor communication skills. For example people would ask a direct question and not receive a response. During times when people were in receipt of support to eat and drink, staff did not communicate with them at all. People and visitors that were able to share their experience stated staff were not always caring and support was variable.

The registered provider did not have robust auditing processes to highlight areas for development and improvement. We found systems that were in place were ineffective as they had failed to identify gaps within the record keeping procedures.

You will see what action we told the registered provider to take at the back of the full version of the report.

Visitors to the service and people living on the ground floor of the service reflected positively about staff and stated they were kind and caring.

Staff were up to date with the training required to undertake their roles and received regular supervision.

This was an unannounced inspection carried out on 21 and 26 April 2016.

Victoria Care Home is located in the village of Rainford, St Helens, providing nursing care and support for up to 53 residents. The service which is part of the Four Seasons Health Care group, is a modern, purpose built facility, with 46 single bedrooms, and six double bedrooms, set over two floors. The ground floor, Alexander unit accommodates people who require nursing care. The Edward unit on the upper floor, accommodates people requiring care and support with dementia and related conditions. At the time of this inspection 51 people were living at the service.

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.

At the last inspections in July and December 2013 we found that the service was meeting all of the regulations that we assessed.

We have made a recommendation that the registered provider considers best practice for use of people’s chairs is considered under the Mental Capacity Act 2005 to ensure that individual’s best interests are considered at all times. Where appropriate people assessed and not having the mental capacity to make specific decisions had supported under the Mental Capacity Act 2005. Staff had received training in the Mental Capacity Act 2005 and demonstrated an awareness of the basis principles of the Act.

We have made a recommendation that registered provider reviews their procedures in relation to reporting significant events to ensure that the appropriate regulations are met. Not all of the notification required had been sent to the Care Quality Commission.

Procedures were in place to protect people from abuse and people told us that they felt safe living at the service. All staff had received training in safeguarding vulnerable people.

People’s medicines were stored appropriately and systems were in place to ensure that people received these when they needed them.

Sufficient staff were on duty to meet the needs of people. Effective recruitment procedures were in place to minimise the risk of people not suitable to work with vulnerable people being employed.

Risks to people’s health, safety and wellbeing were assessed and plans had been put in place help ensure that they received the care and support they required.

People’s dietary needs were planned for and when required, monitored to ensure that people had sufficient amounts to eat and drink.

People were supported by a staff team who received regular supervision, training and support for their role. This meant that the staff team had up to date knowledge of current best practice.

A complaints procedure was in place and people were confident that any concerns they raised would be listened to.

The registered provider had several systems in place to gather people’s views on the service they received. This helped ensure that people were able to comment on the standards of care and support they required on a regular basis.

Regular audits took place around the service to ensure that the environment was safe and people’s care planning documents and medicines were kept up to date.

This inspection was to follow up on a previous inspection in July 2013. At that time the home had failed to meet requirements with respect to maintaining peoples care records. This inspection was to check on progress and improvements made.

We looked in detail at three peoples care records and found they were up to date and accurate. Important information such as daily records of care, assessments and care planning were detailed and had been reviewed by the nursing and care staff.

Prior to the inspection we were sent evidence to show that the care records are regularly audited by senior managers to help ensure consistent standards.

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Comments included, “I can’t remember much about coming here, my sister sorted it all and still sees to it all. She comes every week but its smashing and the food is lovely you can have what you want" and a relative said, "She was assessed in hospital but we were involved and had a big part in finding the right home. We went to quite a few homes. This was the best we could find, some were posher but the atmosphere here was different. It seemed homely and friendly and we were not wrong.”

People experienced care, treatment and support that met their needs and protected their rights. One person told us, “I think Mum has a key worker but you can go to anyone as they all seem to know all about her and what is happening. Take today, the new manager let us in and could tell us mum had two ice creams yesterday.”

The provider had an effective system to regularly assess and monitor the quality of service that people receive. All of the people we spoke with said they had no worries or concerns, but that they could talk to staff if they had any.

Records available in the service were not always kept securely and did not contain information that was accurate and up to date. Clear records support staff to provide efficient, consistent and effective care that meets people’s individual needs.

In the course of our inspection, we spoke to people receiving care, their relatives and members of staff. We asked them questions about the care received, how it was delivered by staff and if it met the needs of the people at the home.

We spent time in the lounge area on the ground floor, observing staff interacting with people. We noted that staff were respectful yet friendly towards people, explaining any intervention. We asked one person about their life at the home; they told us

"I like it here very much. I'm never told what to do, I'm asked what I'd like to do." Another person told us how they had liked a particular light fitting in the home, and requested one for their own bedroom, which was provided. They had also chosen wallpaper for their bedroom, and a picture for a communal lounge.

We spoke to staff on duty at the home. One nurse told us "I am happy here, I've got a good team around me, and many of them have been here for years. There is a good team spirit, it works."

A relative was able to spend time explaining to us, how the home had accommodated both their parents at short notice, and how relieved they had been to find a facility where their parents could stay together as a couple. They said " I can't explain how relieved I am; Mum has put on weight since being here. The staff have gone above and beyond to care for them. I leave here knowing they are happy and well cared for, and that gives me so much peace of mind."

In a letter received in February 2011 a relative wrote 'Please pass on our thanks to all the staff who helped make Mum's stay with you so pleasant. I felt that Mum was treated as an individual not as just another patient'

St Helens Council carried out a contracts monitoring visit on 17 January 2011 and the Quality Monitoring Officer reported:

I spoke to a few residents on the day of the visit and they informed me that they were happy and settled at the home, the staff are very nice and the food is very good. One family member commented that they were very happy with the care at the home and they were always made to feel welcome by the staff. They were able to relax knowing that their relative was being looked after and that the home would contact them if there were any problems. They also informed me that they were aware of how to make a complaint should the need arise.

The home has a fully equipped salon and a hairdresser attends the home every Friday and the service is well accessed by the service users. A chiropodist visits the home on a regular basis and this is also accessed well by the service users. There is a church service provided at the home, some residents are registered with the local dentist and family or staff can chaperone the service user to the surgery. A library service attends the home once a month and occasional days out are organised for the service users. Entertainment is brought into the home twice a month, which includes, singer/dancer for all the residents to enjoy.

The home has a comments and suggestion box in the main reception area and a service user meeting is held every 4-6 months, to enable service users/family/representatives to be included in decision making at the home. The manager informed me she is looking at setting up a service user/family/representative forum in the near future to work towards improving involvement and participation.

The focus of our visit on 1 April 2011 was to observe the care provided for people who have dementia. The first floor of the home is light, bright and spacious which means that people can walk around safely. There is a choice of five lounges so people can find somewhere to sit down that suits their mood, they may also choose to spend time in their own bedroom. Many of the bedrooms had a picture board outside with a photograph of the person and some biographical details to give staff information about their past lives.

The two small lounges are domestic in style and two men were sitting in one of these lounges and three women in another. A member of staff was doing manicures for them. Another lounge is fitted with relaxation equipment. Four people were using this room and all appeared to be very comfortable and relaxed. Another lounge has been fitted out with furniture and equipment, for example a record player, from the mid 20th century to encourage reminiscence

Most people were sitting in the biggest lounge and at least one member of staff was always present. We spoke with the staff about how they support people to make choices about daily living such as what they prefer to eat and what activities they join in. There were many smiles and spontaneous shows of affection between staff and residents. One of the carers was communicating with a resident through another language that was common to both of them.

We were invited to join a meeting that the clinical manager had arranged with the relatives of a person whose health was deteriorating. The person's GP and key worker also attended. All aspects of his care were explained and discussed in a most sensitive and supportive manner. The family's wishes, and any preferences that he himself had expressed, were given great importance and decisions about end of life care were agreed and recorded. It was evident that the family members felt reassured that everything would be done to ensure that he would be pain free and that they would be fully involved with all decisions.

They said that they were very happy with the care that he had received since he came to live at Victoria six months ago. They had planned to move him to a care home closer to his home, but he was so settled and had built up such a good relationship with the staff that they decided not to do this.

The Quality Monitoring Officer from St Helens Council reported that the appropriate consent had been sought for important decisions to include the appropriate use of bed rails and advance care decisions to include DNR (do not resuscitate). There were capacity assessments found in two of the files one of which was detailed and clearly documented the decision to be made, the other was not so clear.

One file included a service user that was on the care of the dying pathway. Documentation was found to be clear, respectful of the service users wishes, person centred, consent sought where needed, GP consent, advance decisions in place and signed appropriately, next of kin details etc.

In a letter received in March 2011, a family member wrote 'After a day or so Mum was in a deep sleep but the staff still came in day and night, they turned her every two hours to stop her getting bed sores, they washed and changed her at least once a day and changed her bedding daily, they brushed her hair and put perfume on her so she looked and smelled beautiful, all the time explaining to mum what they were doing even though she was unaware of what was happening around her. The girls came in every morning to say hello and they kissed mum every night as they were leaving.'.

A letter received in September 2010 read 'We would like to express our heartfelt thanks for the care and dignity you gave to Dad whilst he was with you. He had been in and out of hospital and another home since January and nobody throughout all that time treated him with the humanity that you and your team showed him'.

A member of the care management team was part of the contract monitoring visit to Victoria in January 2011 and her findings were:

The care plans were found to be detailed and the documentation was accurate in that appropriate risk assessments were found to be in place. The care plans were person centred and easy to read and I was able to build a mental picture of the service user on reading the detail in the file. Nutrition and Waterlow charts were found in the files and were appropriately recorded. The files included socialisation, body maps, pain scales, and photographs of injuries, identification photographs and very clear documentation.’ Overall the care manager was happy with the care files.

A letter received in March 2011 said 'From Christmas Mum stopped eating and drinking properly but the staff tried to coax her with all kinds of titbits and spent a lot of time trying to get her fluid intake up.'

The Quality Monitoring Officer from St Helens Council found that:

A 'Malnutrition Universal Screening Tool' is in use at the home, service users are weighed regularly monthly or weekly depending on needs. Portable scales are used and there is a scale on the one of the hoists also. Food and fluid intake charts are in use at the home and there is a four weekly roll on menu in place and the cook is flexible in meeting the needs of the service users. Read the full inspection report (PDF)