New Victoria Nursing Home

Updated 29 February 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by an inspector, a regulatory coordinator, and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

New Victoria Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. New Victoria Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced. Inspection activity started on 17 November 2023 and ended on 28 November 2023. We visited the service on both of these dates.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 8 people who used the service, 1 visitor and 1 relative about their experience of the care provided. We spoke with 7 members of staff including care assistants, nurses and the registered manager. We walked around the home to make sure it was homely, suitable, and safe. We observed the care and support people received. This helped us understand the experience of people who could not talk with us.

We reviewed multiple medicine administration records, medicines stocks and storage and observed medicines administration. We reviewed 5 people's care records and looked at 4 staff files in relation to recruitment. We looked at a variety of records relating to the management of the service, including policies and procedures.

Updated 29 February 2024

About the service

New Victoria Nursing Home is a care home providing personal and nursing care to 27 people at the time of our inspection. The service can support up to 30 adults living with dementia or mental and physical health conditions. Accommodation consists of single room accommodation with additional communal spaces for people’s comfort and enjoyment.

People’s experience of using this service and what we found

The service was not always safe. We found care records were not always accurate. Where risks to people were identified, recorded documentation to lessen the risk was not in place. We found concerns with the cleanliness and maintenance of the environment we have made a recommendation around this.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The governance and quality checks in the home did not consistently promote the delivery of safe care and treatment. The registered provider had not established good governance in line with best practice and to ensure compliance with regulations.

The service was caring. One person told us, " Yes, they [the staff] are extremely caring." We observed positive interactions between people. Staff and people were comfortable in each other’s company. Staff treated people with respect and upheld their privacy and dignity. Staff knew people well and encouraged them to be as independent as possible.

People told us they felt safe. There were enough staff to meet people's care and support needs. Staffing levels were increased if people required additional care. The service worked with a wide range of key organisations who were also involved in people's care.

There was a positive staff culture at the service and staff were happy in their roles. People, relatives, and staff were complimentary about the registered manager.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 19 August 2021). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

At our last inspection made a recommendation about the safe management and recording of medicines. At this inspection we found although improvements had been made there were still improvements to be made.

Why we inspected

The inspection was prompted in part due to concerns received about staffing, medicines and the management of the home. A decision was made for us to inspect and examine those risks.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, documentation, governance, recruitment and consent at this inspection.

We have also made a recommendation the provider considers current guidance in relation to infection prevention and control.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider and request an action plan following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.