This inspection took place on 1, 21 February, 20 and 21 March 2017 and was unannounced. This meant staff and the registered provider did not know that we would be visiting.

Victoria House is registered to provide nursing and residential care for 68 people and the service operates across five distinct units. The home caters for people with a physical disability, people with mental health needs and people with dementia some of whom may need nursing care. At the time of the inspection 64 people were using the service.

At the last inspection on 29, 30 April and 11 May 2015 we found improvements were required to the staffing levels. The service was found to be in breach of regulations 18 (Staffing). We rated the service as ‘Requires Improvement’ in one domain and overall ‘Good’.

Following our last inspection the registered provider sent us information, in the form of an action plan, which detailed the action they would take to make improvements at the service.

At this inspection we found that the registered provider had ensured sufficient skilled and experienced staff were deployed at the service.

Prior to the inspection the local authority commissioners discussed with us issues they had found at the service such as improvements needed in the general cleanliness on units; upkeep of the building, the delivery of care on the nursing unit for people living with dementia and ensuring it was clear which staff were allocated to undertake one-to-one support with people.

When we first visited the registered provider was in the process of ensuring all of the external building was cleaned and guttering was replaced where needed. A deep clean had been completed throughout the service and plans were in place to complete a refurbishment programme on the nursing unit. We completed our last days of the inspection in March 2017 in order to see the works that had been undertaken. These we found enhanced the living environment.

The registered provider had also put plans in place to refurbish other units and make needed repairs to the chapel. We saw that following the registered manager discussing with the need to repair the ceiling of the chapel and to test the stair lift engineers came out the same day to check them and determine what repairs were needed. The repairs were then scheduled for the next week. We noted that the kitchen worktops in the unit for people with physical disabilities were chipped and posed an infection control risk. The registered manager undertook to replace those immediately.

At each visit we found that the service was clean and personal, protective equipment (PPE) was available for staff.

People and relatives we spoke with told us they felt the service was safe. Risks to people using the service were assessed and plans put in place to reduce the chances of them occurring.

Safeguarding and whistleblowing procedures were in place to protect people from the types of abuse that can occur in care settings. People’s medicines were managed safely. There was enough staff deployed to keep people safe.

The registered provider’s recruitment processes minimised the risk of unsuitable staff being employed. Staff received mandatory training in a number of areas, which assisted them to support people effectively, and were supported with regular supervisions and appraisals. People’s rights under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) were protected.

People were supported to maintain a healthy diet and to access external professionals to monitor and promote their health. The registered provider was in the process of introducing a new menu, which was designed by an external contractor and dietician. The new menu included menu choices such as poached salmon and lamb cutlets.

People and their relatives spoke positively about the staff at the service, describing them as kind and caring. Staff treated people with dignity and respect. Staff knew the people they were supporting well, and thro

We completed this inspection on 22 December 2014. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting. At this inspection we were following up the significant concerns identified during the inspection in November 2014.

At that inspection we found that there were breaches of 11 of the regulations relating to care from regulation 9 to 26, The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Also there were breaches of regulation 18 of the Care Quality Commission (Registration) Regulation 2009. We had serious concerns about the service provided in the Regent House unit and took immediate action to reduce the risk posed to people using this unit. The people who used the Regent House unit moved out on 6 December 2014.

Victoria House is registered to provide nursing and residential care for 68 people and the service operates across four distinct units. Up until September 2014 the home had three units; one for people with a physical disability; one residential unit for people living with a dementia; and a nursing unit for people living with a dementia. In September 2014 the provider started using a fourth unit, which they named Regent House. The provider described this service, as a specialist unit for the rehabilitation of people with enduring mental health needs which was staffed with registered mental health nurses 8am to 8pm seven days a week. This service is no longer provided as we imposed a condition to ensure this service was not operated at the home.

At the November 2014 inspection we found that there were breaches of virtually 13 of the regulations relating to care from regulation 9 to 26, The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Also there were breaches of regulation 18 of the Care Quality Commission (Registration) Regulation 2009.

We informed the provider of these concerns and received a comprehensive risk assessment identifying how these issues would be addressed on 8 December 2014. In the subsequent week the provider sent confirmation that action had been taken and provided a range of detailed information to support these assurances.

When we visited on 22 December 2014 we found that the work had been completed to ensure the service was meeting the remaining people’s needs.

We found that the repairs had been completed. We were also provided with a refurbishment plan detailing how the general décor of the home would be improved and how they would ensure each unit would meet the specific needs of the client group using it. Also action had been taken to ensure the ambient temperature of the home did not compromise people’s health. Staff were actively monitoring temperatures throughout the day and ensuring if they increased action was taken to ensure people remained hydrated.

At the previous inspection we found that the provider expected the registered manager to make the clinical decisions around whether people were admitted and to determine if they required residential or nursing care. The registered manager was not a nurse and did not have the appropriate clinical skills to make decisions about whether people needed nursing care for their needs or not. The provider took action to resolve this matter and a deputy registered manager who was a RMN came into post the week of our inspection.

The provider’s statement of purpose and service user guide did not provide clear information for people who used the service around what the purpose of each unit. By 22 December 2014 these documents had been reviewed and contained clear admission criteria and were accurate.

We found that staff on the unit for people with a physical disability were being supported to consider goals associated with rehabilitation. An occupational therapist had reviewed the unit and following their recommendations the provider had purchased a range of adapted kitchen equipment, which we found were in situ. This meant people could be assisted to live more independent lifestyles.

We found that families had been invited to join the reviews and all of the people using the service had been seen by representatives from their placing authority.

Staff had some understanding of the requirements of the Mental Capacity Act 2005 but had not fully introduced either the principles or the appropriate documentation into the home. They had requested Deprivation of Liberty Safeguard (DoLS) authorisations for three people. Staff had not considered preventing other people from leaving units was a deprivation of liberty. The staff had not considered how these environmental restrictions of the unit could exacerbate their level of agitation and had not considered whether the person could safely access other areas in the home or the garden. On 22 December 2014 we found staff had received refresher training and were appropriately applying for DoLS and considering how to treat people in the least restrictive ways.

When we concluded our inspection the provider had resolved most of the breaches of regulations. Three remained, which you can see at the back of the full version of this report along with the enforcement action we took.

At the last inspection in July 2013 we found that the staff needed to ensure appropriate action was taken when people were deprived of their liberty. Also on the day of the visit temperatures on the third floor of the home were excessive and this had the potential to lead to people becoming unwell.

At this inspection we found that the provider had installed an air conditioning unit on the third floor and this assisted in reducing the temperatures to within acceptable ranges. Also the new manager was looking at the current way the space was used, as at the time of the inspection the floor was divided into two units and this decreased the flow of air.

We found that staffing levels had been increased overnight and the manager was looking at the way staff were deployed across the home during the night. She had started to look at why two separate units were operated on the third floor rather than one unit, which would have provided access to a wider range of communal areas and improved access to the available staff.

The people who lived at the home that we met found it difficult to think about recent events or at times, to have a conversation. From our observations, we found that the care staff supported people in a sensitive and empathetic manner. We found that staff were extremely committed to ensuring people received good care. We found that staff took appropriate action when people who lacked capacity may have restrictions imposed or be deprived of their liberty.

At the last inspection in July 2013 we found that staff had not completed the required mandatory training. Apart from staff not being up to date with this training, additional client specific training was needed. This included training in respect of managing behaviour that challenged and how to use break away techniques . None of the staff had received this training.

During this inspection we reviewed the training matrix and found that staff had completed all the necessary mandatory training. We saw that over the last six month staff had completed basic food hygiene, COSHH, safeguarding adults and moving and handling training. There was also sufficient staff on duty who were now up to date with basic first aid training to cover each shift.

We noted that 13 staff had received training around managing challenging behaviour and break away techniques. The acting manager also confirmed that plans were in place to ensure more staff received this training and that action was taken that ensured mandatory annual refreshers for physical intervention training were conducted.

Whilst at the home we discussed the current staffing arrangements and the acting manager provided evidence to confirm these were increased to ensure people’s needs were met.

During the visit, we spoke with five people who used the service and two relatives. The people we spoke with told us that they liked the home; thought the staff were excellent at their jobs; and felt care needs were met. They said, “If not for the support of the staff I wouldn’t be moving on to my own place”, “They are a lovely set of people” and “I like them all.” The people we spoke with who used the unit for people with a physical disability told us that they were very pleased with the service and felt they were supported to lead independent lives.

Many of the people who lived at the home found it difficult to think about recent events or at times, to have a conversation. From our observations, we found that the care staff supported people in a sensitive and empathetic manner. We found that staff were extremely committed to ensuring people received good care.

We found that the staff needed to ensure appropriate action was taken when people were deprived of their liberty. On the day of the visit, temperatures within the home were excessive: this had the potential to lead to people becoming unwell. The size of the home had led to the current numbers of staff finding it difficult to consistently support people across the 24 hours. Also staff had not received the planned mandatory training; or training around meeting the specific care needs of people; or how to deal with challenging behaviour.

During the visit, we spoke with seven people who used the service. All of the people we spoke with told us that they really liked the home; thought the staff were excellent at their jobs; and felt their care needs were met. They said, “The staff are smashing” and “They are a lovely bunch and this is like home from home.” The individuals we spoke with who used the unit for people with a physical disability told us that they were very pleased with the service and felt able to lead independent lives. People told us about the range of activities provided and that they found the activity coordinators were very good at their job.

Many of the people who lived at the home found it difficult to think about recent events or at times, to have a conversation. During the visit we used a specific way of observing care

to help to understand their experience of the service. From our observations, we found that the care staff supported people in a sensitive manner.

From our observations and discussions with people we found that care staff worked in ways that supported people to lead fulfilling lives and respected people’s decisions. We found that staff had a good understanding of how to best meet each person’s care needs. We found that the manager had successfully implemented and sustained a range of improvements and these were making sure the service met the needs of the people.

The visit took place because we were following up a warning notice issued about the building at the last inspection and concerns raised around staff training. Therefore when talking with people we concentrated on these specific areas. We spoke to seven people who used the service and two relatives. People said "The staff are really helpful and treat me well'', ''I find the staff know what my needs are and do make sure I get the care I need" and ''The girls are always at hand if I need them so I would say the care is excellent''. Relatives told us ''I find the staff are very kind and really know how to care for the people here.''

The visit took place because we were following up concerns raised at the last two inspections in September and November 2011. At the last inspection a warning notice was issued in respect of ensuring infection control practices were effective. Therefore when talking with people we concentrated on the specific areas raised in this warning notice. We spoke with twelve people who used the service and one relative and everybody told us that they thought the home was always clean. People said ''The staff work hard to keep the place clean'' and ''I've always thought the place was fine and the staff are always busy keeping it tidy''.

The visit took place because we were following up concerns raised at the last inspection about care records and medication. Therefore when talking with people we concentrated on those specific areas raised in the last inspection. We spoke to eleven people who used the service and five relatives. People said; "The staff are really helpful and treat me like a part of their family'', ''I find the staff know what my needs are and do make sure I get the care I need" and ''The girls are always at hand if I need them so I would say the care is excellent''. Relatives told us ''I find the staff are very kind and really know how to care for the people here, they are really patient and considerate.''

I get up when I want and I go out when I want and can go into town with staff.

The girls help me, they take me seriously and listen to me

The food is terrible, nothing has any flavour and there's not much choice, there should be more variety. I have raised this but they don’t listen.

Food is sound; I have put on weight since I came here.

There have been improvements to the nursing unit environment, it's much nicer now

We inspected Victoria House on 29, 30 April and 11 May 2015. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.

At the last comprehensive inspection in November 2014 we found that there were multiple breaches of the regulations relating to care. In light of this we varied the provider’s conditions of registration to prevent people with certain types of conditions being admitted to Victoria House.

We revisited the home in December 2014 and found significant improvements had been made. We did, however find that the home was in breach of regulations relating to: assessing and monitoring the quality of service provision; respecting and involving service users; and records.

At this inspection we reviewed the action the provider had taken to address the above breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We found that the provider and manager had continued to oversee the way the care and treatment was delivered and the overall operation of the home; had improved the way staff worked to support people to be as independent as possible; had improved record keeping practices and these had led to the home meeting the above regulations.

Victoria House is registered to provide nursing and residential care for 68 people and the service operates across three distinct units. The home caters for people with a physical disability and people with dementia some of whom may need nursing care. At the time of the inspection 44 people lived at the home.

In December 2014 the registered manager resigned. 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 this inspection we found a new manager was in post and they had applied to become the registered manager but noted they commenced working at the home mid-April 2015.

During the inspection we found that the new manager had commenced a range of processes designed to monitor and assess the ongoing performance of the home, such as audits. We found that this review had led to actions plans being developed. We saw that the processes had led the manager to quickly gain in-depth knowledge of the home and areas for improvement.

We found, as the manager had, that closer scrutiny needed to be given to ensuring sufficient staff were on duty with the skills, experience and competency to meet people’s needs. The provider had converted the unit, Regent House to meet the needs of older people. This meant the 44 people were accommodated in the physical disability unit; middle floor nursing unit, top floor nursing unit and the Regent House unit.

Although the provider completed a needs analysis and this led to 1 nurse and eight staff being on duty during the day and 1 nurse and 5 care staff overnight. No consideration was given to the design and layout of the building. This layout of the building meant, particularly overnight, one staff member was left to cover whole floors and they did not have swift access to support. We observed that even with one member of staff acting as a float it took 40 minutes for the lone worker to get the support they needed to complete positional changes. Also some of the people displayed marked behaviours that challenge and this had not been factored in to how many staff were needed to ensure people remained safe in these units. We found that the provider had not risk assessed the impact that the building and lone working would have upon the delivery of safe care.

We saw there were systems and processes in place to protect people from the risk of harm. However, these needed to be improved as staff were not reporting incidents to senior staff.

We found that in between December 2014 and the new manager starting much of the useful dementia friendly items had been removed but not replaced with anything meaningful. Also the activities coordinators had left and were in the process of being replaced. This change meant that people were not engaged in meaningful activity and occupation throughout the day and we heard from visitors this had been usual for the home since February 2015. The manager was aware of this issue. They discussed the plans for improving this aspect of people’s lives. We found that the manager had obtained a range of items people could use to entertain themselves; they had created new spaces in the home for people to go; they had employed a new activity coordinator and they were in the process of creating a new café.

Staff had a greater understanding of the requirements of the Mental Capacity Act 2005 and had appropriately requested Deprivation of Liberty Safeguard (DoLS) authorisations. Staff had been working hard to ensure capacity assessments were completed in line with the Mental Capacity Act 2005 code of practice. They and the manager recognised that they were still developing the skills needed to always complete these accurately and they needed more space on the sections relating to people’s ability to take on board information to write their analysis.

We found that the manager had worked closely with staff to ensure they provided care and treatment that was effective. We saw that all interactions between staff and the people who used the service were person-centred and supportive. We found that this had led to improvements in individual’s presentation and we were able to hold full conversations with people who used the service. This change meant we could talk to people about their care.

We found that care records now reflected the treatment people received and staff routinely ensured, when necessary individuals were referred to external health care professionals.

Staff took action to monitor people’s weight and ensured they were provided with sufficient food and fluid. The cook designed menus that were nutritious and offered a range of alternatives including fortified for people who were at risk of losing weight.

We found that medication practices had improved and staff were administering prescribed medicines safely.

We heard how the manager was in the process of reviewing people’s needs to ensure the home could meet their needs. Where this was not the case the manager had taken action to ensure the person’s needs could either be met or they moved to more suitable accommodation.

We found that staff were appropriately recruited and had received a wide range of training including condition specific training such as courses related to supporting people who were living with dementia.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff or relatives to hospital appointments.

People told us they were now confident that should they have a complaint this would be fully investigated by the manager and resolved to their satisfaction.

The manager and staff had reviewed and updated all of the records maintained at the home such as care records, audits, policies and training information.

We found that the building was very clean and was being maintained. We found that all relevant infection control procedures were followed by the staff at the home.

When we concluded our inspection the provider had resolved the breaches of regulations identified at the last inspection. We found that action was needed to address aspects of one of the regulated activities regulations 2014, of the Health and Social Care Act 2008, which you can see at the back of the full version of this report.