Archived: Victoria Lodge

Updated 24 October 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 20 September 2017 and was unannounced. This meant that the service was not expecting us. The inspection team consisted of one adult social care inspector.

Before we visited the service we checked the information we held about this location and the service provider, for example we looked at the inspection history, provider information report, safeguarding notifications and complaints. We also contacted professionals involved in caring for people who used the service; including the local authority commissioners through our information sharing processes.

Prior to the inspection we contacted the local Healthwatch who is the local consumer champion for health and social care services. They give consumers a voice by collecting their views, concerns and compliments through their engagement work.

Before the inspection, the provider completed a Provider Information Return. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

During our inspection we observed how the staff interacted with people who used the service and with each other. We spent time watching what was going on in the service to see whether people had positive experiences.

At the inspection we spoke with five people who used the service, the deputy manager, the manager, the providers and four care staff.

We also reviewed records including; two staff recruitment files, five medicines records, safety certificates, two care plans and records, two staff training records and other records relating to the management of the service such as audits, training and supervision records, minutes of meetings and policies.

Updated 24 October 2017

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

Victoria Lodge is based in a residential area of Saltburn within walking distance of the sea front. The home provides personal care for people living with a mental health illness. The service is registered for 14 people and on the day of our inspection there were 12 people using the service.

At our last inspection in July 2016 we found the service was in breach of registration and was rated as ‘requires improvement’. We found during this inspection that the provider had made improvements to their best interest decision processes and recording and had recruited a new manager.

We found quality assurance surveys took place, to check people’s views of the service The service had been regularly reviewed through a range of internal and external audits. We saw that action had been taken to improve the service or put right any issues. People who used the service and their representatives were regularly asked at meetings for their views about the care and service they received.

The service did not have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

A manager was newly appointed to the role and at the time of our inspection was in the process of registering with the CQC.

The atmosphere at the service was relaxed and very welcoming. People who used the service told us they felt at home and had a good rapport with the staff and the providers.

We saw staff interacting with people in a person centred and caring way. We spent time observing the support that took place in the service. People were always respected by staff and treated with kindness. Staff communicated with people well and where necessary used their skills positively to reassure people who used the service.

We found the service adhered to the principles of the Mental Capacity Act 2005 and where people were unable to make decisions for themselves, best interests’ decisions had been put in place. These had involved social workers, family members, advocates and other professionals.

People were encouraged to enhance their wellbeing on a daily basis by taking part in activities that they valued. Staff spent their time positively engaging with people on an individual basis in meaningful activities. People were supported to go out regularly too.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible, the policies and systems in the service supported this practice.

People’s care plans were written in plain English and they also included a personal history and described individuals preferences and support needs. These were regularly reviewed and were written in a person centred way. ‘Person centred’ is when a person is at the centre of planning their care and their preferences are respected.

Care plans contained risk assessments. These identified risks and described the measures and interventions to be taken to ensure people were protected from the risk of harm. The care plans showed that people’s health was monitored and referrals were made to other health care professionals where necessary, for example: their GP, chiropodist, mental health practitioners, dentist or optician.

People who used the service were supported on a one to one basis or by sufficient numbers of staff to meet their individual needs and wishes in a person centred way.

Staff training records, showed staff were supported and able to maintain and develop their skills through training and development opportunities that were accessible at the service. The staff confirmed they attended a range of learning opportunities.

Staff had regular supervisions and appraisals with the deputy manager, where they had the opportunity to discuss their care practice and identify further mandatory and vocational training needs. Records that showed there were robust recruitment processes in place. However, some staff records were not always complete; this was rectified during the inspection.

We observed how the service administered medicines. We looked at how records were kept and spoke with senior care staff who administered medicines and we found that the process was safe.

People were encouraged to eat and drink sufficient amounts to meet their needs. They were offered a varied selection of drinks and homemade snacks. The daily menu was flexible and reflective of people’s likes and dislikes and offered varied choices and it was not an issue if people wanted something different.

A complaints and compliments procedure was in place. This provided information on the action to take if someone wished to make a complaint and what they should expect to happen next. People also had their rights respected and access to advocacy services if needed.