We conducted an unannounced inspection at Victoria Cottage on 24 May 2018. Victoria Cottage is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Victoria Cottage accommodates up to 18 people in one building. On the day of our inspection, nine people were living at the home; all of these were older people, some of whom were living with dementia.

This service is also registered as a domiciliary care agency. This means it can provide personal care to people living in their own homes. At the time of our inspection, no one was being supported in their own home.

At the last inspection in May 2017, we asked the provider to take action to make improvements to risk management, in particular risks associated with falls. During this inspection, we found that although the management of falls risk had improved, risk management in other areas had deteriorated. We also identified concerns in relation to safeguarding people from abuse, staff training and competency and governance and leadership. We found five breaches of the Health and Social Care Act 2008 regulations. You can see what action we told the provider to take at the back of the full version of the report.

There was no registered manager in post at the time of our inspection. The previous registered manager had left the home in January 2018. 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. There was a service manager in post who told us they were planning to register. We will monitor this.

During our inspection we found the service was not safe. People were not always protected from risks associated with their care and support. People were placed at risk of choking as risks were not assessed and staff did not have access to guidance to inform their care and support. Moving and handling risk assessments had not been updated to reflect changes in people’s needs, which meant staff did not have the most up to date information about how to safely support people. People were subject to unsafe and restrictive interventions as staff were not provided with information about how to manage behaviours resulting from anxiety and distress. Serious incidents were not investigated; this meant action had not been taken to reduce the risk of reoccurrence.

People were not protected from abuse and improper treatment. We found evidence of a number of incidents that had not been referred to the local authority safeguarding adults team for investigation. The cause of unexplained marks to people’s skin were not investigated. Infection control and prevention measures were not effective, this exposed people to the risk of infection spreading. People could not be assured that good hygiene practices were followed, effective cleaning procedures were not in place for some items of equipment and some areas of the home.

There were enough staff to meet people’s needs and ensure their safety. Safe recruitment practices were in place to reduce the risk of people being supported by unsuitable staff. Overall, medicines were stored and managed safely. However, medicines errors were not always identified and investigated, and topical creams were not always administered as required.

People were supported by staff who did not always have appropriate training or support. Temporary agency staff did not have training in key areas and when staff moved into new roles within the home they were not given additional training to support them to fulfil their duties.

Systems to protect people from risks associated with eating and drinking were not alw

We inspected Victoria Cottage Residential Home on 11 May 2017. The inspection was unannounced. The home is owned and managed by Sun Care Homes Limited. It is registered to provide accommodation for up to 18 older people. On the day of our inspection seven people were living at the home. The service is also registered to provide personal care to people living in the community, no one was being supported in their own home on the day of our inspection.

We carried out an unannounced, focused inspection of this service on 17 January 2017. Breaches of legal requirements were found. During this inspection we found that improvements had been made across a number of areas and some further improvements were still required. We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach was in relation to safe care and treatment. You can see what action we told the provider to take at the back of the full version of the report.

The service had a registered manager in place at the time of 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.

There was a risk that people may not be adequately protected from the risk of falls. Other risks associated with people’s care and support were effectively assessed and managed.

There were systems and processes in place to minimise the risk of abuse. People received their medicines as prescribed and these were managed safely.

There were enough staff to provide care and support to people when they needed it and safe recruitment practices were followed. People were supported by staff who received training, supervision and support.

People were enabled to make decisions. Where a person lacked capacity to make a certain decision they were protected under the Mental Capacity Act 2005. We found two isolated incidents were people’s rights under the MCA had not been protected and the service took swift action to address this.

People were supported to eat and drink enough, however improvements were required as to how people’s nutrition and hydration was recorded. People had access to healthcare and their health needs were monitored and responded to.

People received caring support from staff who knew them and cared about their wellbeing, they were treated with dignity and had their right to privacy respected. People were involved making choices relating to their care and were supported to maintain their independence.

People received person centred care which met their needs. Their preferences were respected and they were provided with opportunities for social activity. Where possible people and their families were involved in planning their care and support.

People were supported to raise issues and staff knew how to deal with concerns if they were raised. People and staff were involved in giving their views on how the service was run.

Most of the systems in place to monitor and improve the quality of the service were effective. However issues related to the day to day practice of staff were not always identified. Some confidential information was not stored securely.

The management team were passionate about making improvements to the service and had brought about a positive change in the quality of the service. Swift action was taken to address areas of concern raised during this inspection.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key

We carried out an unannounced focused inspection of this service in April 2016 and found breaches of regulation. We carried out an unannounced focused inspection to check for improvements in October 2016 and we found continued breaches of regulation. After the focused inspection, the provider wrote to us to say what they would do to meet the legal requirements. We returned to the service to carry out a further focused inspection on 17 January 2017 and we found the provider had not yet made all of the improvements to meet the legal requirements.

We undertook this focused inspection to check how the provider was progressing with their action plan and to check if they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Victoria Cottage Residential Home on our website at www.cqc.org.uk.

We inspected the service on 17 January 2017. The inspection was unannounced. Victoria Cottage Residential Home is owned and managed by Sun Care Homes Limited. It is registered to provide accommodation for up to 18 older people. On the day of our inspection eight people were using the service.

The service did not have a registered manager in place at the time of our inspection and had not had one in place since September 2015. 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 provider had engaged another consultant since we last inspected in order to try and drive improvements in the service. We found this had brought about improvements in some areas but there were still a number of further improvements needed.

People were still not protected from the risk of harm, due to a lack of effective systems. Risks in relation to people’s daily life were not always assessed or planned for. Medicines were not always managed safely to ensure people were receiving their medicines as prescribed.

People were supported to make decisions if they had the capacity to do so. However people who did not have the capacity to make certain decisions were still not always protected by the Mental Capacity Act 2005. People were not always adequately supported with their nutritional needs. More training had been given to staff and people now were supported by staff who had the knowledge and skills to provide safe and appropriate care and support.

Some improvements had been made in relation to how care was planned for and delivered. However we found this had not happened for everyone which resulted in the risk of those people not always being cared for appropriately.

People were involved in giving their views on how the service was run and their concerns were listened to and acted on.

A new manager had started working in the service since we last inspected the service and was working to establish an open and inclusive culture in the service. There had been improvements made to implement systems to assess and monitor the quality of the service, however there were further improvements needed. This resulted in ongoing breaches in regulation.

Although we found there had been improvements to the quality of the service, the overall rating for this provider remains ‘Inadequate’ and the service therefore remains in ‘Special measures’. We could not improve the rating from inadequate because to do so requires consistent good practice over time. We will check this during our next planned Comprehensive inspection.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is th

We carried out an unannounced comprehensive inspection of this service in January 2016 and we found breaches of regulation. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements. We returned to the service to carry out a focused inspection on 19 April 2016 and we found the provider had not made the improvements to meet the legal requirements. The provider sent us an action plan telling us how and by when they would make the improvements to meet the regulation they continued to be in breach of.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Victoria Cottage Residential Home on our website at www.cqc.org.uk.

We inspected the service on 11 October 2016. The inspection was unannounced. Victoria Cottage Residential Home is owned and managed by Sun Care Homes Limited. It is registered to provide accommodation for up to 18 older people. On the day of our inspection nine people were using the service.

The service did not have a registered manager in place at the time of 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.

We found that although the registered provider was continuing to work with a consultant to drive improvements in the service and continued to upgrade the environment, this had not resulted in people being given safe, effective and responsive care and support.

People were still not protected from the risk of harm, due to ineffective systems in place to protect them. Risks in relation to people’s daily life were not always being assessed or planned for. Medicines systems were now managed safely and people were receiving their medicines as prescribed.

Although more training had been given to staff, people were supported by staff who still did not have all of the knowledge and skills to provide safe and appropriate care and support. People were supported to make decisions if they had the capacity to do so. However people who did not have the capacity to make certain decisions were not protected by the Mental Capacity Act 2005. People had restrictions placed upon them without the required authorisation to do so and care was not planned to ensure it was delivered in the least restrictive way.

There was a lack of planning and delivery of safe and responsive care and this resulted in the risk of people not being cared for appropriately. People felt they could raise concerns if they wished to.

There was still a lack of appropriate governance and risk management framework and again this resulted in us finding ongoing breaches in regulation and negative outcomes for some people who used the service. People were not being involved in giving their views on how the service was run and the systems in place to monitor and improve the quality of the service provided were ineffective.

The overall rating for this service remains ‘Inadequate’ and the service therefore remains in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line w

We carried out an unannounced comprehensive inspection of this service on 13, 14 and 19 January 2016. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to regulations 11, 12, 13, 16, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Victoria Cottage Residential Home on our website at www.cqc.org.uk.

We inspected the service on 19 April 2016. The inspection was unannounced. Victoria Cottage Residential Home is owned and managed by Sun Care Homes Limited. It is registered to provide accommodation for up to 18 older people. On the day of our inspection nine people were using the service.

The service did not have a registered manager in place at the time of 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.

We found that although the registered provider had engaged a consultant to drive improvements in the service and had spent money on upgrading the environment, this had not resulted in people being given safe, effective and responsive care and support.

People were still not protected from the risk of harm, due to ineffective systems in place to protect them. Risks in relation to people’s daily life were not being assessed or planned for. Staffing levels had not been increased but as there were less people using the service there were enough staff to support people. Medicines were not managed safely and people could not be assured they would receive their medicines as prescribed.

Although more training had been given to staff, people were supported by staff who still did not have the knowledge and skills to provide safe and appropriate care and support. People were supported to make decisions if they had the capacity to do so. However people who did not have the capacity to make certain decisions were not protected by the Mental Capacity Act 2005. People had restrictions placed upon them without the required authorisation to do so and care was not planned to ensure it was delivered in the least restrictive way.

There was a lack of planning and delivery of safe and responsive care and this resulted in people not being cared for appropriately. People felt they could raise concerns if they wished to.

There was still a lack of appropriate governance and risk management framework and this resulted in us finding ongoing breaches in regulation and negative outcomes for some people who used the service. People were not involved in giving their views on how the service was run and there was a lack of effective systems in place to monitor and improve the quality of the service provided.

The overall rating for this service remains ‘Inadequate’ and the service therefore remains in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preven

We inspected the service on 13, 14 and 19 January 2016. The inspection was unannounced. Victoria Cottage Residential Home is owned and managed by Sun Care Homes Limited. It is registered to provide accommodation for up to 18 older people. On the day of our inspection 15 people were using the service.

The service did not have a registered acting manager in place at the time of our inspection. A registered acting 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 were not protected from the risk of harm due to ineffective systems and the environment they lived in. Risks in relation to people’s daily life were not being assessed or planned for. Staffing levels left people at risk of being supported in an unsafe way. Medicines were not managed safely and people could not be assured they would receive their medicines as prescribed.

People were supported by staff who did not have the knowledge and skills to provide safe and appropriate care and support. People were supported to make decisions if they had the capacity to do so. However people who did not have the capacity to make certain decisions were not protected by the Mental Capacity Act 2005. People had restrictions placed upon them without the required authorisation to do so and care was not planned to ensure it was delivered in the least restrictive way. People were not supported appropriately with their ongoing healthcare.

People were supported by staff who did not have guidance on people’s current needs and how they should be supported. Staff were caring towards people but were working in an environment which restricted them from providing care which was tailored around the individuals they were supporting. People were not given the opportunity to have stimulation or follow their hobbies and interests.

There was a lack of appropriate governance and risk management framework and this resulted in us finding multiple breaches in regulation and negative outcomes for people who used the service. People were not involved in giving their views on how the service was run and there was a lack of systems in place to monitor and improve the quality of the service provided.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rat

Prior to our visit we reviewed all the information we had received from the provider. During the visit we spoke with four people who used the service and one relative and asked them for their views. We also spoke with three care workers and the manager. We looked at some of the records including the care files for three people. We observed the support people received from staff and carried out a tour of the building.

We found people gave consent to their care and received care and support that met their needs. People’s individual characteristics were respected. A person told us, “Everything is nice, we say what we want.” A relative told us their relation was, “Well looked after.”

We found people were safeguarded from abuse. A relative told us, “I didn’t know what to expect but I am not worried, I think they are perfectly safe here.”

We found the provider was making some improvements to the building so it was safe ands suitable. A person told us, “It is brilliant now the stairs have gone, it is much easier for me.”

The provider took action to ensure people’s health and welfare needs were met by sufficient numbers of appropriate staff. A person told us, “There are enough staff most of the time, but if they are busy I have to wait, sometimes everyone wants something at the same time.”

We found the provider assessed and monitored the quality of the service. A person said, “Everyone talks to us so we can always say if we want something or something isn’t right.”

This inspection was carried out to ensure the provider had complied with actions we took following our last inspection where we found the provider was non complaint. Prior to our visit we reviewed all the information we had received from the provider including the action plan they sent us following our last inspection detailing how they would become compliant. During the visit we spoke with two care staff, the manager and one of the providers. We also looked at some of the records held in the service. We were unable to get any views from people who used the service about the areas we were inspecting.

We found the provider did not act in accordance with legal requirements when someone did not have the capacity to consent.

We found people did not always receive care and support as described in their plan of care.

We found staff had been trained so they knew how to ensure people were safeguarded from abuse.

We found staffing numbers had been increased so there was always sufficient and suitable staff available.

We found the provider had put a system in place to regularly asses and monitor the quality of the service.

We saw staff speaking with people who used the serviced in a respectful manner and knocking on people’s doors before entering. A person who used the service told us, “I am treated with respect and dignity. I have not got a single complaint.”

We asked four people about the care they received and they all said it was good. One person told us, “I have no problems with the care, if I want something doing they do it.” A person who was on bed rest told us, “I am happy with the care I have. They (staff) put cream on my skin and it has not broken down.”

We asked three people who used the service if they felt safe in the home and they all said they did. One person said, “If I press my bell they nearly always come. If there is something going on they come and apologise.”