This inspection took place on 19 and 23 March 2018. The inspection was unannounced on the first day. This meant the staff and provider did not know we would be visiting. The second day was announced.

Victoria Court is a domiciliary care agency. Victoria Court is a large complex of houses where people can access the domiciliary care agency which is based on site. Not all people living at Victoria court received personal care and we only inspected those people who received a regulated activity. It provides a service to older adults. Not everyone using Victoria Court services receives a regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene, eating and medication. Where they do we also take into account any wider social care provided. At the time of our inspection, 17 people were using the service.

There was no registered manager however; the manager of the service had applied to the Care Quality Commission to become the registered manager and that this was being progressed. 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.

At the last inspection we rated the service overall ‘Good’ however, at this inspection we found that improvements were required and rated the provider ‘Requires improvement’. At the last inspection we found the provider did not always follow The Mental Capacity Act 2005, as capacity assessments and best interest decisions had not been recorded. At this inspection we found some improvements had been made with capacity assessments in place however, not all best interest decisions had been completed, when required. We made a recommendation that the provider research the MCA to ensure best practice is followed.

We found improvements were needed to fully ensure effective systems and processes were in place to monitor and improve the service. Audits did not always identify when actions were required and not always completed in a timely manner. Records were not always robust to show that actions had been completed.

We found risk assessments had not always been followed by staff to ensure people’s safety and avoid potential harm.

Staff did not always receive supervisions and appraisals in line with the provider’s policy however, staff told us they felt supported and were provided with the appropriate training.

Medicines were safely administered most of the time however, medication errors had not always been reported and actions had not been taken to mitigate risks. 'As required' medicines were administered accordingly and protocols were in place for staff to follow.

There were sufficient staffing levels however; some people felt that more staff were required due to waiting times. Recruitment procedures were safe for employed staff however, the relevant checks to ensure agency staff were eligible to work with vulnerable people had not always been completed.

People told us they felt safe and staff had a clear understanding of the procedures relating to safeguarding and whistleblowing. People told us staff were kind and they felt listened to by staff. Staff respected people’s privacy and dignity at all times.

People were supported with their health and nutritional needs and were provided with a range of food and drink.

People were encouraged to remain independent and make choices about their care. Care plans were detailed and included people's preferences and likes and dislikes, which promoted person centred care.

Complaints had been responded to with outcomes recorded. People using the service told us they felt confident to discuss any concerns with the provider. Incidents and accidents that had been reported were monitored and m

We inspected Victoria Court on 23 March 2016. This was an announced inspection. We gave the provider 48 hours’ notice because we needed to be sure the registered manager would present. The service was last inspected in October 2013 and found to be meeting the regulations at that time.

The service comprises of 50 apartments with communal areas which include a library, atrium and a bistro. The service is registered to provide personal care to older people in their own apartment if they require this.

The service had a registered manager. 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 were systems and processes in place to protect people from the risk of harm. Staff were aware of the different types of abuse and what would constitute poor practice.

Safety checks of the building and equipment had been completed appropriately.

Assessments were undertaken to identify people’s care and support needs. Care records reviewed contained information about the person's likes, dislikes and personal choices.

There were risk assessments in place for people who used the service. The risk assessments and care plans had been reviewed on a regular basis, but at times the care plan had not been updated following a change in need. Recognised tools to assess risks around nutrition and pressure care were not being used.

The registered manager and staff we spoke with had an understanding of the principles and responsibilities in accordance with the Mental Capacity Act (MCA) 2005. We found capacity assessments and best interest decisions were not always recorded in peoples care records.

Systems were in place for the management of medicines so people received their medicines safely. The audit process did not check frequently enough people’s medication charts which meant errors were not highlighted in a timely way.

There were enough staff employed to provide support and ensure people’s needs were met. Effective recruitment and selection procedures were in place and we saw appropriate checks had been undertaken before staff began work.

Staff told us the registered manager was supportive. Staff had received regular and recent supervision and most had received an annual appraisal. Staff training was up to date.

People and families told us staff treated people with dignity and respect. Staff showed compassion, were patient and gave encouragement to people.

People told us they had access to a wide range of activities and people told us they enjoyed them.

People were provided with their choice of food and drinks which helped to ensure their nutritional needs were met.

Staff at the service worked with other healthcare professionals to support the people. Staff worked and communicated with social workers, occupational therapists, hospital staff as part of the assessment and on-going reviews. Care plans did always contain robust health needs information.

The registered provider had a system in place for responding to people’s concerns and complaints. People told us they knew how to complain and felt confident staff would respond and take action to support them.

There were systems in place to monitor and improve the quality of the service provided. Staff told us the service had an open, inclusive and positive culture

We spoke with four people who used the service, one relative, three members of staff and the manager of the service. People who used the service said they were very happy at Victoria Court. They said the staff were, “Fantastic” and “Very, very good”.

People told us they were given information about the service and met with a member of staff who checked that they understood the support available. People’s needs were assessed before they started to use the service. Where appropriate, relatives had been involved in the assessments and support planning. There were arrangements in place to deal with emergencies. Staff were had received Basic Life Support training and knew how to summon assistance and support people who were unwell.

People were protected from the risk of abuse. The provider had taken reasonable steps to ensure staff, relatives and people who used the service were able to identify signs of abuse and knew how to report concerns about abuse.

Appropriate arrangements were in place in relation to the supply, safekeeping, administration and recording of medicines administered by the staff.

Staff received appropriate professional development. They had undergone a structured induction period, had regular supervision and felt well supported by the manager. Staff training and development needs were identified and staff were encouraged to obtain further qualifications.

The provider had an annual audit programme detailing specific tasks to be completed each month. Monthly resident and service user meetings had been held. People had been able to raise issues of concern and receive feedback about issues they had previously raised. One of the people we spoke with said, “The residents meetings are good, the staff take notice."