About the service: Victoria Park (Coventry) accommodates up to 32 people in one adapted building. It provides residential care to people over the age of 65. During our visit 25 people lived at the home and two people were in hospital. The home is located in Coventry, West Midlands.

People’s experience of using this service:

¿People felt safe and were protected from avoidable harm.

¿Enough staff were on duty during our visit.

¿Staff were recruited safely and received on-going support and training to be effective in their roles.

¿Staff knew people well and risk management plans contained clear instructions for staff to follow.

¿The environment was clean and staff followed good infection control practices.

¿Medicines were managed safely, and people were supported to access healthcare professionals when needed.

¿People’s needs were assessed before they moved into make sure it was the right place for them to live.

¿People received information in a way they could understand and chose how to live their lives.

¿People’s nutritional and hydration needs were met. Staff understood people’s dietary needs.

¿Staff cared about people and were responsive to their needs. Care plans supported staff to provide personalised care.

¿People were supported to be independent, their privacy was respected, and their dignity was maintained.

¿People’s end of life wishes were documented to ensure their wishes would be respected at the end stage of life and following their death.

¿People were occupied with meaningful activity and had opportunities to maintain positive links with their community.

¿ People and relatives were happy with the care they received and spoke positively about the leadership of the service.

¿Complaints were being managed in line with the provider’s procedure.

¿ Systems to monitor the quality and safety of the service were effective. ¿Lessons were learnt when things had gone wrong. The provider shared learning across the organisation to drive continual improvement.

¿Feedback from people, their relatives and staff was welcomed to drive forward improvement. Action had been taken in response to the feedback.

¿At this inspection we found the evidence supported a rating of 'Good' in all areas. More information in 'Detailed Findings' below.

Rating at last inspection: At our last inspection in May 2017 we rated the service as 'Requires improvement' overall.

Why we inspected: This was a planned comprehensive inspection that was scheduled to take place in line with Care Quality Commission scheduling guidelines for adult social care services.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received, we may inspect sooner.

During our previous inspection visits to Victoria Park in July 2016 and May 2017, we identified medicines were not consistently managed safely. We could not be sure medicines were disposed of safely. We found the provider to be in breach of the regulation in regards to ‘safe care and treatment’. Issues of concern related to medicine management were not being identified and addressed in a timely way. We served a warning notice to the provider. We asked them to make the necessary improvements as stipulated in the warning notice within a short timescale.

During our inspection visit on 29 August 2017 and 19 October 2017, we checked people at the home received safe care and received their medicines as prescribed. We found people received their medicines safely when they needed them and sufficient action had been taken to meet the requirements of the warning notice. However, we found improvements were needed in regards to other aspects related to people receiving safe care.

Risks associated with people’s care were identified but we found risks were not always effectively managed. Staffing arrangements meant some people did not receive care and support in a timely manner.

Accidents and incidents were recorded and acted upon by the registered manager. Equipment that people used was checked to make sure it was safe although records were not always in place to confirm this.

Staff were subject to recruitment checks to make sure they were safe to work with people at the home.

We carried out an inspection of Victoria Park on 17 and 22 May 2017. The inspection was unannounced.

Victoria Park provides accommodation with personal care for up to 32 people. There were 28 people living in the home at the time of our inspection. Some people were living with dementia.

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.

The service was last inspected on 28 July 2016 when we found breaches in the regulations in relation to supporting people who lacked capacity to make decisions, providing safe care and treatment to people and good governance. We asked the provider to take the necessary steps to ensure the required improvements were made. At this visit we found actions had been taken which had resulted in some improvements. This was in regards to working with people who lacked capacity and the management (good governance) of the home. However, we identified further actions were required to ensure the home consistently operated safely and effectively.

During our last inspection we found medicines were not consistently managed or administered safely which meant people did not always receive their medicines as prescribed. Following the inspection, we continued to receive reports in relation to concerns about medicine management. During this inspection we found continued concerns with medicine management, this was in relation to administration, storage and recording of medicines. The provider had not ensured sufficient action had been taken to ensure medicine management was safe.

During our last inspection we found improvements were needed to ensure staff understood the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards and the need to ensure people consented to care. During this inspection we found the necessary improvements had been made. The provider had identified people whose care plans contained some restrictions to their liberty and had submitted the appropriate applications to the authorising authority in accordance with the legislation. Staff understood the principles of the Mental Capacity Act 2005 and sought people's consent before supporting them.

Overall, staff knew about risks associated with people’s care and knew what they needed to do to keep people safe. However, it was not clear from records that risks were managed consistently to keep people safe. Accidents and incidents were recorded and the process to report these to CQC had improved. These were reviewed each month by the provider so they could identify any actions required to reduce the risk of them happening again.

People told us they felt safe living at the home and there were usually enough staff available to meet their needs. People felt that most of the time, staff knew how to support them and staff told us they had received the training they needed to effectively meet people’s needs.

Recruitment checks were carried out prior to staff starting work at the home to make sure they were suitable to work with people who lived there.

New staff received an induction to the home when they started their employment and received training based on the Care Certificate, to develop their skills to care for people effectively. There was a training plan in place to ensure all staff completed the required training, some staff were due to update their training.

Most people said they enjoyed the food and there were choices of drinks and meals provided. We could not be sure that people who needed to have their food and drink monitored, always had enough to eat and drink, as records were not always completed correctly. People were referred to health professionals to ensure their health and

We carried out an inspection of Victoria Park on 28 July 2016. The inspection was unannounced.

Victoria Park provides accommodation with personal care for up to 32 people. There were 25 people living in the home at the time of our inspection. Some people were living with dementia.

A registered manager was not 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. The registered manager left in June 2016.

The service was last inspected on 4 February 2015 when we found a breach in regulation in relation to staffing arrangements. We asked the provider to take the necessary steps to ensure the required improvements were made. At this visit we found improvement had been made in this area. People told us they felt safe living at the home and there were enough staff on duty to meet their needs. Staffing arrangements had been reviewed and changes had been made to ensure there were enough suitable staff employed to meet people’s needs.

At our last inspection we recommended the provider sought advice and guidance in relation to assessment of mental capacity and best interest decisions because where there was a doubt a person had capacity to make a decision an assessment of their capacity had not been completed. During this visit improvements had not been made. The provider was not compliant with their responsibilities in relation to the Mental Capacity Act (2005) and where people lacked capacity to make decisions, action was not being taken to ensure they were appropriately supported. This meant the rights of people who were unable to make important decisions were not protected.

Risks associated with people’s care were not always identified, documented or managed well to ensure a consistent approach to the management of risks. Incident and accident forms were not always completed so analysis and action to reduce the recurrence of these could be taken.

People had some concerns about how they received their medicines. Medicines were not consistently managed or administered safely, which meant people did not always receive their medicines as prescribed. We could not be sure that the disposal of medicines was safe. We received mixed feedback from people and their relatives about the management of the home. The provider had not ensured that effective quality assurance procedures were in place to assess and monitor the quality and safety of the service people received. Both the provider and the temporary manager (known as a ‘turnaround manager’), were committed to making on-going improvements to ensure people received care and support that met their needs and preferences. We refer to the turnaround manager as the manager in the body of this report.

Procedures were in place to protect people from harm. Staff had an understanding of what constituted abuse, but some staff needed to refresh their knowledge by completing safeguarding training. The provider had taken measures to minimise the impact of unexpected events for example, fire.

New staff received an induction when they first started their employment at the service and training in health and social care to develop their skills further. However, we observed some staff did not always put their learning into practice.

Recruitment checks were carried out prior to staff starting work at the home to make sure they were suitable for employment.

People told us they enjoyed the food and told us they were able to have drinks and snacks throughout the day. We could not be sure people whose dietary and fluid intake required monitoring received enough to eat and drinks as records were not always completed correctly. People were referred to health professionals to ensure their health and well-being was ma

This inspection took place on 4 February 2015 and was unannounced.

Victoria Park provies accommodation, personal care and support to older people. It is registered to accommodate a maximum of 32 people. At the time of our visit there were 26 people living there. The accommodation is set out over two floors with a lounge and dining area on each floor.

The home had a registered manager in post who was present for our 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. The registered manager had been in post for five weeks.

People and staff told us that due to staffing levels there was sometimes a delay in responding to people’s needs. During our visit we observed occasions when people had to wait for support after requesting assistance.

The Mental Capacity Act 2005 (MCA) sets out how to support people who do not have capacity to make a specific decision. Where there were doubts about people’s capacity to make specific decisions, capacity assessments had not been completed. We have made a recommendation that the provider should seek advice about capacity assessments.

People told us they felt safe living at Victoria Park and staff knew how to protect people against the risk of abuse. Staff understood how to keep people safe and that any concerns should be reported to the manager. There was detailed information for staff about how to manage identified risks to people, but we found this was not always being carried out in practice. The provider had plans to ensure people were kept safe in the event of an emergency or unforeseen situation.

We found staff missed opportunities to engage with people when delivering care and support. There was no activities co-ordinator in post at the time of our visit so people’s social needs were not being met. Staff were provided with information so they could be supportive of people’s spiritual and cultural needs. Family and friends were able to visit at any time of the day.

Care plans were very detailed about people’s routines and how they preferred their care and support to be provided by staff. Staff had a good knowledge of the people they were caring for, but did not always deliver care in accordance with people’s preferences.

People were supported to eat and drink enough to maintain their health and well-being and to attend appointments with external healthcare professionals.

There was a new management team in post. The new manager had already identified areas that required improvement and staff told us they found her open, available and responsive.

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

We visited Victoria Park on 28 August 2013. We arrived at the home at 6.45am. At the time of our visit there were 28 people living there. We spoke to 14 people, two visiting relatives, five members of staff and the manager.

People told us they felt involved in their care, that their views were listened to and they were supported in maintaining as much independence as possible.

We saw there was sufficient information in people's care plans to support staff in delivering care safely and in a way people preferred. People we spoke with told us they were happy with the care they received. The service was proactive in contacting other healthcare professionals when the care and health needs of people living in the home had changed.

People told us they liked the food served in the home. One person told us, "I think this is a good place, especially the food. Lots of choice." The menu provided people with a range of suitable and nutritious food.

People we spoke with were happy with the staff who looked after them. One person said, “They are very good to me. They try to help me all they can.” Another told us, "Staff are very polite."

We were satisfied the home had systems in place to monitor the quality of service provision.

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 this inspection. Their name appears because they were still a Registered Manager on our register at the time.

When we inspected this service in September 2012 we found that people's care was not consistently planned and delivered in a way that ensured their welfare and safety. We also found there were not enough suitably qualified, skilled and experienced staff to safely meet the health and welfare needs of people using the service. We told the provider they must make improvements.

In November 2012 the provider sent us an action plan to tell us how they were going to make the improvements required. The purpose of this inspection was to check whether outcomes had improved for people using the service.

We met and spoke with ten of the 14 people using the service at the time of our inspection. We spoke with a relative of one person using the service. Their comments included,

“The care is great. I have no worries.”

“They do what we need.”

“They look after us well, but I’d really like to have a greater variety of activities.”

We also spoke with seven staff members and the area quality manager who was visiting the care home at the time of our inspection.

We found that improvements had been achieved in the outcome groups we assessed.

Victoria Park was an existing service that was purchased by a new provider in October 2011. This is our first visit to the service since it was registered with the new provider.

We made unannounced visits to this care home on 31 August and 3 September 2012.

We spoke with ten of the 26 people using the service at the time of our visit and spent time observing their experiences in the care home. We looked at three people’s care records in detail.

We spoke with four care staff. We looked at some records relating to the running of the home, such as staffing training records and staff duty rosters.

We saw that staff treated people respectfully. We saw that people had received the support they needed to maintain their personal appearance and hygiene. People looked groomed and appropriately dressed. We noticed that people’s skin and fingernails were clean.

We found that people’s care plans were not always updated when their needs increased. We were concerned that people may not get the support they require to promote their wellbeing and safety.

People told us staff were helpful and friendly, but they always appeared busy, One person said, “Sometimes I have to wait if they are helping someone else.” We were concerned that there were not enough staff working on the floors to effectively support people’s needs.