We inspected Victoria House on the 26 and 28 September 2018. This was an unannounced inspection.

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

Victoria House Care Home provides accommodation and personal care for up to 26 older people living with a range of health care needs. Some people required support with memory loss and dementia, whilst others were reliant on care staff to assist them with their personal care and health needs.

Victoria House Rest Home was inspected in August 2015, where it was rated overall as inadequate. A focussed inspection took place in October 2015 to follow up on concerns in relation to safety at the home and we found the provider had not made suitable improvement and the service continued to be rated as inadequate. CQC took appropriate enforcement action and the service was placed into special measures. We inspected in May 2016 to see what improvements the provider had made to ensure they had met regulatory requirements. Considerable improvements had been made and the provider was meeting all regulations. We inspected on the 20 and 25 July 2017 was to see if the improvements had been sustained. Not all improvements seen at the May 2016 inspection had been sustained and we found breaches of regulation and we took further appropriate enforcement action. In December 2017 we undertook a focussed inspection to see if the provider had made the necessary improvements. Improvements had been made and the warning notices met within the set timescale.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and to check that the provider had followed their action plan and confirm that the service now met legal requirements. We found that whilst improvements had been made there were further improvements needed to ensure that improvements were consistent and sustained.

This is the second consecutive time the service has been rated Requires Improvement.

Whilst the provider had progressed quality assurance systems to review the support and care provided, there was a need to further embed and develop some areas of practice that the existing quality assurance systems had missed. This included updating care plans when an identified need or directive of care changed. For example, a deterioration in mobility and nutritional needs. People’s specific personal care challenges were not always recorded clearly and responded to.

A number of audits had been developed, including those for accidents and incidents, care plans, medicines and health and safety. Maintenance records for equipment and the environment were up to date, such as fire safety equipment and,e hoists. Policies and procedures had been reviewed and updated and were available for staff to refer to as required. Staff said they were encouraged to suggest improvements to the service. Relatives told us they could visit at any time and, they were always made to feel welcome and involved in the care provided.

People spoke positively of the home and commented they felt safe. One person said, "I feel safe, staff look after us and I see my doctor when I need to." A visitor told us, “I leave after a visit knowing Mum is safe.” Our own observations and the records we looked at reflected the positive comments people made.

Most care plans reflected people’s assessed level of care needs and care delivery was person specific, holistic and based on people's preferences. Risk assessments included falls, skin damage, behaviours that distress, nutritional risks including swallowing problems and risk of choking, and moving and handling. For example, pressure relieving mattresses and cushions were in place for those who were susceptible to skin damage and pressure ulcers. The care plans also highlighted health risks such as

We inspected Victoria House on the 28 December 2017. This was an unannounced focussed inspection.

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

Victoria House Care Home provides accommodation and personal care for up to 26 older people living with a range of health care needs. Some people required support with memory loss and dementia, whilst others were reliant on care staff to assist them with their personal care and health needs.

Victoria House Care Home was inspected in August 2015 where it was rated as inadequate overall and the CQC took enforcement action. A focussed inspection took place in October 2015 to follow up on concerns in relation to safety at the home and we found the provider had not made suitable improvement and the service continued to be rated as inadequate. CQC took further enforcement action and the service was placed into special measures. We inspected in May 2016 to see what improvements the provider had made to ensure they had met regulatory requirements. We found considerable improvements had been made and the provider was meeting all regulations. We inspected on the 20 and 25 July 2017 was to see if the improvements had been sustained. Not all improvements seen at the May 2016 inspection had been sustained. We found that the management of medicines was unsafe. People were also at risk of not receiving appropriate care and support because guidance about how people should be supported was not always in place where needed. We also found that quality monitoring systems needed further development to ensure best practice in all areas, for example, repositioning, fluids and nutrition. At this time we served Warning Notices to ensure peoples safety and well-being and further improvements to the organisational audits.

We undertook an unannounced focused inspection of Victoria House on the 28 December 2017. This inspection was done to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection in July 2017 had been made. The inspector inspected the service against two of the five questions we ask about services: is the service safe and well led, This is because the service was not meeting some legal requirements. This report only covers our findings in relation to the key questions of whether the service is Safe and Well-led. No risks, concerns or significant improvement were identified in the remaining Key Questions through our on-going monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection. You can read the report from our last comprehensive inspections, by selecting the 'all reports' link for Victoria House on our website at www.cqc.org.uk.

This inspection found that improvements had been made and the breaches of regulation had been met. Whilst these improvements had been made, time was now needed to fully embed the new systems to sustain improvement. The rating over all remains 'requires improvement' as the provider needs to be able to demonstrate they can sustain into the future. This will be assessed at their next comprehensive inspection.

At this inspection there was improved managerial oversight to ensure documentation was kept up to date and ensured people received safe, effective, caring and responsive care. A range of audits had been introduced and completed either weekly (for medicines) or monthly. When audits had identified issues there was evidence of recorded actions taken to address the issues. For example, poor recording of medicines administered had led to the further training and competencies. The management and storage of medicines were safe. Care documentation

Victoria House Care Home provides accommodation and personal care for up to 26 older people living with a range of health care needs. Some people required support with memory loss and dementia, whilst others were reliant on care staff to assist them with their personal care and health needs.

The inspection took place on the 20 and 25 July 2017 and was unannounced. There were twenty people living at the home at the time of our inspection, including one person who was in hospital.

Victoria House Rest Home was inspected in August 2015. A number of breaches were identified and it was rated as inadequate and the CQC took enforcement action. A focussed inspection took place in October 2015 to follow up on concerns in relation to safety at the home and we found the provider had not made suitable improvement and the service continued to be rated as inadequate. CQC took further enforcement action and the service was placed into special measures. We inspected in May 2016 to see what improvements the provider had made to ensure they had met regulatory requirements. We found considerable improvements had been made and the provider was meeting all regulations. This inspection on the 20 and 25 July 2017 was to see if the improvements had been sustained. Not all improvements seen at the May 2016 inspection had been sustained We were informed the management structure had changed three times following the last inspection in 2016 and that there had been an increase in staff turnover.

There had been no registered manager in post since April 2017. 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 and associated Regulations about how the service is run. From April 2017 to July 2017 an acting manager had been in post but left the organisation a week before this inspection. At the time of the inspection there was an acting manager at Victoria House who was supported by the provider. The acting manager had been in post for a week.

Although people told us they felt safe living at the service we found the provider had not assured people’s safety in areas related to the management of medicines and had not ensured people received their prescribed medicines. Some people were at risk of not receiving appropriate care and support because guidance about how people should be supported was not always in place where needed. Accidents and incidents were not all recorded appropriately and steps had not been taken by the staff to minimise the risk of similar events happening in the future. There was a lack of management overview of accidents and incidents.

Quality monitoring systems and daily documentation completed by staff needed further development to ensure best practice in all areas, for example, repositioning, fluids and nutrition.

Staff had an understanding of the Mental Capacity Act 2005 and acted in accordance with its principles whilst supporting people. However there were areas within the documentation that was contradictory in respect of their mental capacity and decision making.

People were supported to take part in a range of activities, maintain their own friendships and relationships. Staff related to people as individuals and took an interest in what was important to them. The provider was in the process of recruiting a new activity co-ordinator.

People’s nutritional needs were met with referrals made to dieticians and Speech and Language Therapists (SALT) when needed. People preferences and special dietary needs were met and weights were monitored regularly. People were offered a choice of food and drinks throughout the day, with alternatives available if people requested them.

Staffing levels were monitored and reviewed regularly to ensure levels were safe and appropriate to meet people’s needs. However some nega

Victoria House Care Home provides accommodation and personal care for up to 26 older people living with a range of health care needs. Some people required support with memory loss and dementia, whilst others were reliant on care staff to assist them with their personal care and health needs.

There were seven people living at the home at the time of our inspection. Including one person who was in hospital and another who was staying at Victoria House for respite care.

Victoria House Rest Home was inspected in August 2015. A number of breaches were identified and it was rated as inadequate and the CQC took enforcement action. A focussed inspection took place in October 2015 to follow up on concerns in relation to safety at the home and we found that the provider had not made suitable improvement and the service continued to be rated as inadequate. CQC took further enforcement action and the service was placed into special measures. This inspection took place on 4 and 5 May 2016 and was a full comprehensive inspection to see what improvements the provider had made to ensure they had met regulatory requirements.

At this inspection we found that considerable improvements had been made and the provider was now meeting all regulations. However some areas required time to become fully embedded into everyday practice. This included quality monitoring systems and daily documentation completed by staff which needed further development to ensure best practice in all areas. The use of agency staff needed to be reviewed to ensure that all staff who worked at Victoria House understood their responsibilities in relation to daily documentation for people, especially daily charts in place, for example, repositioning, fluids and nutrition. Staff needed to be consistent in their recording of care provided and when completing handover forms to ensure all relevant information was recorded.

Recruitment systems needed to be tighter to ensure all relevant references and checks were available in staff files and any gaps in previous employment history were documented when discussed.

At the inspections in August and October 2015, we found that risk assessment and risk managements practices were poor. Individuals did not have the risks to their health and safety properly assessed or managed. Identified risks to the environment had not been rectified. At this inspection we found that people’s individual risks had been assessed and reviewed. Environmental risks had been addressed with a programme in place to ensure that future checks took place appropriately.

At the inspections in August and October 2015 we found that people had not been supported to ensure their nutrition and hydration needs were met. At this inspection we found people’s nutritional needs were reviewed with referrals made to Speech and Language Therapists (SALT) when needed. People preferences and special dietary needs were met and weights were monitored regularly. Fluid intake was reviewed daily and any changes reported to people’s GPs. People were offered a choice of food and drinks throughout the day, with alternatives available if people requested them.

At the inspections in August and October 2015 we found that people’s medicines were not safely managed. At this inspection we found that extensive improvements had been made to the entire medicines process. Information was in place to support staff and people received their medicines as prescribed.

At the inspections in August and October 2015 we found that accidents and incidents were not consistently documented or investigated. At this inspection we found that a new system or reporting had been implemented. This included clear information regarding the incident, who witnessed it, actions taken and a body map in place to record any injuries. Follow up checks took place and the incident discussed with staff to see if anything could be implemented to prevent the incident reoccurring.

At the inspections in August and Octob

We carried out an unannounced comprehensive inspection of this service on 31 July and 7 & 14 August 11 2015. Breaches of legal requirements were found. After the comprehensive inspection, we issued the provider with a warning notice in relation to Regulation 12. We told the provider they must take action to ensure they met legal requirements by 9 October 2015.

We undertook this focused inspection on 15 October 2015 to check the provider had met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Victoria House Care Home on our website at www.cqc.org.uk

Victoria House Care Home provides accommodation and personal care for up to 26 people who are older or who are living with dementia. Some people had health needs such as diabetes, and others needed support with their mobility. There were nine people living at the home at the time of our inspection.

The home did not have a registered manager, although a new manager had been recruited and was due to start employment in November 2015. A second interim manager was running the home at the time of this inspection. 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.

Risks to people’s safety were not properly assessed. Examples included risk of malnutrition and risk of developing a pressure wound. Not all of the appropriate action had been taken since the last inspection when risks to the property had been identified, for example fire safety and legionella. The provider did not have a suitable schedule to ensure maintenance tasks were completed when required. Incidents and accidents continued to be inconsistently documented and investigated. Appropriate action was not always taken to prevent incidents from re-occurring.

Although staffing levels had improved. People’s care needs had not been assessed to establish what the appropriate number of staff on duty should be. We found several occasions where staff left for breaks together leaving only two staff to support people.

People’s medicines were not safely managed. People did not always receive their medicines as prescribed. People continued to be given medicines regularly when they had only been prescribed it on an as and when needed basis. Medicines administration records remained incomplete so it was not possible to establish if people had received their medicines.

People remained at risk of not having their hydration needs met. Although fluids were readily available for people, individual’s fluid intake was not always properly monitored. People had not had their risk of malnutrition assessed, and appropriate action had not been taken for a person who had been identified as losing both their weight and appetite.

We found continuing breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Care Quality Commission is currently considering the appropriate regulatory response to resolve the problems we found.

At our last inspection in November 2013, we found that the provider was not meeting all the requirements of the Health and Social Care Act 2008.

At this inspection, we found that the improvements required to comply with the regulations in relation to cleanliness and infection control, supporting staff and ensuring that there were systems in place to assess and monitor the quality of the service had been made.

We spoke with four members of staff; these were the manager, two care workers and a domestic worker. We also took information from other sources, including meeting minutes, audit documentation and supervision notes.

The overall appearance of the service was clean and we saw that there were appropriate systems and policies in place in respect to cleanliness and infection control.

We spoke with two care workers during our inspection and were told that they felt valued and supported, and that their training needs had been met. One member of staff told us “It’s a very nice place to work”.

We also saw that the service had quality assurance systems in place to monitor the quality of the service provided, and to gain the views of the people who used the service.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

Most of the people we spoke with who were living at Victoria House told us they enjoyed living at the home and were happy with the care they received.

One person told us "Staff are very good indeed and very friendly," another told us "the food is very good." A visiting relative told us "The regular staff are amazing, they work hard. There are too many agency. My relative's anxiety levels are up because there aren't enough regular staff."

Our visit was facilitated by a senior carer who was in an acting manager position and an interim manager who had been providing support on a consultancy basis for the previous two weeks. We looked at supporting care documentation and staff documentation. Fourteen people were resident at the time of our visit. We spoke with three people who used the service individually and a number of other people who were sitting in communal areas. We spoke with seven staff members and one relative. One staff member told us "I really like it here," another told us "there is a good standard of care but with so many agency staff on it can be difficult".

People told us that they enjoyed living at Victoria House and were always treated with respect and dignity. They told us how they were given choices about their daily life and were involved in planning their care. People described the home as ''a happy home'' and told us that it was a ''good place to live'' and they “felt very safe in the home and could speak with the manager at any time if they had any concerns”.

One person told us how she was planning her birthday with staff and another was keen to tell us about how enjoyable the entertainment was. When we asked residents relaxing in the lounge after lunch to tell us about the food, they all said it was “marvellous, home cooked” and “better than you could ever expect”.

Most people we spoke with were able to tell us that they enjoyed living at Victoria House and were happy. We were told “everyone is very nice” “I am really happy I’m here” and “the food is always very good”.

This inspection took place on 31 July and 7 & 14 August 2015 and was unannounced. Victoria House Care Home provides accommodation and personal care for up to 23 people who are older or who have dementia. Some people had health needs such as diabetes, and others needed support with their mobility. There were 16 people living at the home at the time of our inspection.

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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Most of the people we spoke with said they felt safe living in the home. However, we found a number of significant safety concerns during our inspection. Staff and the registered manager were not clear what their responsibilities were to safeguard people from abuse. We raised six safeguarding concerns with the local authority during our inspection.

Risks to people’s safety were not properly assessed, and management plans that were in place were poor. Examples included falls, risk of malnutrition and risk of developing a pressure ulcer. Action was not taken when risks to the property had been identified, including fire and legionella. Where environmental risks had been identified the provider failed to take appropriate action. The provider did not have a suitable schedule in place to ensure that essential maintenance tasks were completed when required. Incidents and accidents were not properly documented or investigated, and appropriate action was not taken to prevent the incident from re-occurring,

People were not kept safe and did not have their needs met because there were not enough staff. The registered manager and provider did not assess the level of people’s care needs to determine what staffing levels were appropriate to keep people safe. People said “we need more staff” and “at weekends staffing is bad.” While staff tried their hardest they did not have the time they needed to do anything other than meet people’s basic care needs. On person said: “carer’s are really nice, but they don’t have enough time to talk to you”.

People’s medicines were not safely managed. One person did not get their prescribed medicines for eight days because they were out of stock. People were being given medicines regularly when they had only be prescribed on an as and when basis. Medicines administration records were not always completed so it was not possible to establish if people had received their medicines. Medicines were not always stored securely. On several occasions the medicines cupboard was left unlocked and we found a large number of paracetamol in an unlocked drawer in the manager’s office.

Staff were not properly supported with training, supervision and appraisal. Staff had not received training in appropriate subjects such as the Mental Capacity Act (2005) (MCA) and caring for people with dementia. There was no schedule in place for when out of date training would be completed and supervision and appraisals were not up to date. Recruitment practices were not robust and not all of the required information was obtained from staff before they began working for the provider.

Staff were not clear of their responsibilities under the MCA. People’s level of capacity had not been appropriately assessed and information about best interest’s decisions was not recorded accurately. Not all of the relevant Deprivation of Liberty safeguards (DoLs) applications had been made. Where a DoLs had been granted information about the conditions of the DoLs were not recorded in people’s care plans and staff were not aware of what they were. Where a person had Lasting Power of Attorney in place this was not always recorded properly.

People did not have their hydration needs met. People were not offered fluids on a regular basis during the day and did not have access to water or other drinks, except at mealtimes. People’s fluid and nutritional intake was not properly monitored. People did not always have access to health care services. Two people had missed hospital appointments because transport was not organised in time, and other appointments were not accurately recorded in the homes appointment diary. People’s medical conditions were not well understood by staff and appropriate referrals to health care professionals were not always made.

People told us staff were caring. One person said: “the care is very good. If you ask them (staff) anything they will tell answer you”. However we found that people’s care needs, choices and preferences were not understood by all staff. People’s privacy and dignity were not protected and we observed several occasions where people were not supported with their personal hygiene needs in a dignified manner.

People were not always involved in the assessment and planning of their care needs. People’s care plans and records were contradictory and out of date. Staff did not have access to accurate care plans to enable them to meet people’s identified needs. Information about changes in people’s needs was not communicated between staff and people’s needs were not regularly reviewed.

Although the provider had a complaints policy in place, this was not readily available for people and staff to refer to. Complaints were not always recorded or investigated appropriately, and action was not taken to ensure comments or concerns raised were used as an opportunity for learning.

Activities for people using the service were limited. People were not supported to take part in hobbies or other activities that were important to them. All of the people we spoke to said they would like to go on an outing, such as to the shops or for a meal. People were not supported to leave the home and be involved in the community, except when they were attending a medical appointment.

Leadership was not visible from the provider or registered manager. They did not understand their responsibilities and quality monitoring was poor. Many of the issues highlighted at this inspection had not been identified by the registered manager or provider. Records were inaccurate and not always kept securely. Not all of the relevant notifications had been sent to CQC as required by law.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.