The inspection took place on 20 March 2017. The inspection was unannounced.

Victory Care Home was registered to provide accommodation and personal care without nursing for 52 people. There were 50 people living at the home on the day of our inspection. The service was in the process of an extensive refurbishment, comprising of an extension to the building which plans to add a further nine bedrooms, lounge, dining room and laundry room. The people living in the home were all living with dementia and some had other health conditions they required support with.

Victory Care Home was purpose built as a care home. Set at ground level, the premises comprised of a main building and three ‘wings’ giving a smaller more personal feel to the home. Hallways and corridors were decorated in colours that were pleasing to the eye. Lounge and dining room seating was available in each wing but people were able to, and encouraged, to move around and sit where they wished. Pleasant seating areas were available around the outside of the premises where people could sit out when the weather permitted. There were plans to refurbish these areas once the building works were complete.

At the last Care Quality Commission (CQC) inspection on 19 March 2015, the service was rated Good in all domains and overall.

At this inspection we found the service remained good.

There was a registered manager in post who had been registered manager at the last 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.

People continued to be safe, the provider continued to have systems in place to safeguard people from abuse. Staff understood their responsibilities in this area well and said they would have no hesitation in raising concerns, confident they would be listened to and action would be taken. Medicines were managed safely and effectively.

The registered manager made sure individual risks were identified and guidance was in place to make sure risks were managed well. People had a comprehensive care plan that provided detail of the individual support they required. People and their family members were involved in developing and reviewing their care plan.

People were supported to eat and drink enough to meet their needs. They also received the support they needed to maintain their health and well-being and to access healthcare services.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The provider and staff understood their responsibilities under the Mental Capacity Act 2005.

The staff had a caring approach, supporting people to maintain their independence as far as possible with dignity and respect. People’s privacy was understood by staff who recognised the importance of it.

Staff were well supported through one to one supervision meetings, training and regular staff meetings to keep them updated and ensure their personal development was valued. The registered manager provided good leadership. They checked staff were focussed on people

experiencing good quality care and support. People and staff were encouraged to provide feedback about how the service could be improved. This was used to make changes and improvements that people wanted.

The provider had a robust approach to quality assurance, making sure systems were in place to check the quality and safety of the service.

Further information is in the detailed findings below.

This inspection was carried out over nine hours by an inspector who worked to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People had been cared for in an environment that was safe, clean and hygienic. There were enough staff on duty to meet the needs of the people living at the home and each shift was led by a senior carer who could access records and respond to emergency situations. There was a plan in place to enable people’s care to continue should a foreseeable emergency occur, for example a power failure.

We found that staff underwent robust recruitment process, that included written information about their skills and experience, their fitness to carry out the role, at least two references and criminal records checks.

We found that care and treatment records did not contain all of the information required to ensure that people who used the service were protected from the risk of receiving unsafe or inappropriate care or treatment. This was because we found that for some people their records were not being completed in such a way as to enable health issues to be followed up and to keep staff informed of a person’s most up to date care needs. Compliance actions have been set for this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Whilst proper policies and procedures were in place we found that people’s human rights were not protected because the manager of the service was not taking reasonable steps to ensure that staff understood and were trained in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). We saw that where appropriate people’s capacity was not assessed and that where a person’s liberty had been restricted the Deprivation of Liberty Safeguards process had not been followed. This meant that it was not always possible for the registered manager to demonstrate that decisions were in people’ s best interest. Compliance actions have been set for this and the provider must tell us how they plan to improve.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and that they knew them well. We spoke to three people who used the service and two relatives of people who used the service, one person who used the service said “Staff treat me with respect and I am able to make choices”, a relative said “I visit every other day, Mum is treated very well by staff, they are always friendly and respectful.” This meant that there was a relaxed and respectful choice based culture within the home.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers were patient and gave encouragement when supporting people. We saw that staff interacted positively with people who used the service and people we talked with about the service told us that staff were caring and friendly; we observed staff offering people choices. We talked with five people who used the service including their relatives. All of the people we talked with were happy with the care they received. People told us that the staff were caring, one person said “I cannot fault the staff, they are excellent, I am very happy living at Victory Care Home”, Another person said “My mum is safe here, staff come straight away if they are needed, they always make sure my mum is well presented and safe”.

Is the service responsive?

People’s needs had been assessed before they moved into the home. We saw that each person had a named key worker and that systems were in place that enabled care plans to be reviewed and updated. We observed that staff asked people for their views and permission before providing any care or treatment. Records confirmed people’s preferences, interests, aspirations and diverse needs had been recorded, however it was not always demonstrated that care and support had been provided in such a way as to ensure that it met their wishes. This was because people who used the service or their representatives were not always being asked to sign and agree their care plans and assessments before the service was delivered. People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

Is the service well-led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. We saw that people who used the service were asked for their feedback about the service they received, that they had opportunities to participate in residents and relatives meetings and that people felt confident they would be listened to if they complained. Two people we talked with who used the service told us that if they wanted to raise any issues they could tell any member of staff, they said that “The manager of the service was nice and friendly”.

The inspection was carried out on 19 and 20 March 2015 and was unannounced.

At the previous inspection in April 2014 we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The breaches were in relation to the application of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) and the completion of records about people’s care. The provider sent us an action plan telling us they would be meeting the regulations by 1 September 2014. At this inspection we found they were meeting the regulations.

The service provided accommodation and personal care for older people some of whom may be living with dementia. The accommodation was adapted for people living with dementia and provided in a single story purpose build premises arranged in three units. There were 47 people living in the service when we inspected.

There was a registered manager employed at the service. 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 Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. Restrictions imposed on people were only considered after their ability to make individual decisions had been assessed as required under the Mental Capacity Act (2005) Code of Practice. The registered manager understood when an application should be made. Decisions people made about their care or medical treatment were dealt with lawfully and fully recorded.

People felt safe. Staff had received training about protecting people from abuse and showed a good understanding of what their responsibilities were in preventing abuse. Staff were trained to spot the signs of abuse in people living with dementia. The management team had access to and understood the safeguarding policies of the local authority.

The registered manager and care staff assessed people’s needs and planned people’s care to maintain their safety, health and wellbeing. Assessments and care plans were reviewed as people’s needs changed or their dementia became more challenging. Risks were assessed and management plans implemented by staff to protect people from harm.

There were policies and a procedure in place for the safe administration of medicines. Staff followed these policies and had been trained to administer medicines safely.

People had access to GPs and their health and wellbeing was supported by prompt referrals and access to medical care if they became unwell. There were good links with the community district nursing team to promote people’s health and wellbeing. Additional training and skills development was provided to staff so that they understood how to manage people with behaviours that may challenge.

People and their relatives described a service that was welcoming and friendly. Staff provided friendly compassionate care and support. People were encouraged to get involved in how their care was planned and delivered.

Staff upheld people’s right to choose who was involved in their care and people’s right to do things for themselves was respected.

The registered manager involved people in planning their care by assessing their needs when they first moved in and then by asking people if they were happy with the care they received. Staff received training about dementia and knew people well. People had been asked about who they were and about their life experiences. This helped staff deliver care to people as individuals.

Incidents and accidents were recorded and checked by the registered manager to see what steps could be taken to prevent these happening again. The risk in the service was assessed and the steps to be taken to minimise them were understood by staff.

Managers ensured that they had planned for foreseeable emergencies, so that should they happen people’s care needs would continue to be met. The premises and equipment in the service were well maintained.

Recruitment policies were in place. Safe recruitment practices had been followed before staff started working at the service. The registered manager ensured that they employed enough staff to meet people’s assessed needs. Staffing levels were kept under constant review as people’s needs changed.

Staff supported people to maintain their health by ensuring people had enough to eat and drink. All of the comments about the food were good.

If people complained they were listened to and the registered manager made changes or suggested solutions that people were happy with.

People felt that the service was well led. They told us that the management team were approachable and listened to their views. The registered manger and provider monitored health and safety within the service to prevent accidents. The care being delivered and the development of the service was focused on recognised best practice for people living with dementia.