Our inspection took place on 11 & 12 May 2016 and was unannounced. Our last inspection of the service took place in March 2015 and the provider was rated as Requires Improvement.

Victoria Lodge is registered to provide accommodation and personal care to a maximum of 63 older people who may have a diagnosis of Dementia. At the time of the inspection there were 59 people living at the home.

There was a registered manager at the home. 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 told us they felt there were not enough staff to meet their needs and that they had an extended wait when support was needed. However, we observed that there were sufficient numbers of staff available. We saw that staff had undergone appropriate recruitment processes to ensure they were safe to work and had access to ongoing training and supervision to support them in their role.

We saw that staff had received training in how to give medication and were observed doing this by the registered manager to ensure they remained competent in this. However, we found there were errors in the recording of medication given that meant the provider was unable to evidence these medications had been given as prescribed.

People were given choices by staff and had their rights upheld in line with the Mental Capacity Act 2005. Where people lacked capacity to make decisions, best interests meetings were held to ensure their rights were maintained.

We saw that choices were given at mealtimes but people had expressed that they were not always satisfied with the meals made available to them. We saw that the registered manager was taking action to improve the quality of food.

Staff had a kind and caring approach. People told us they were treated with dignity and we saw that people had access to advocacy services when required. Staff had a good understanding of people’s needs and knew their preferences with regards to their care.

People were aware of how to make complaints. We saw that no complaints had been made but the registered manager could explain how any complaints would be managed.

Systems were in place to monitor the quality of the service. Where areas for improvement were identified, these were acted upon by the registered manager. We saw that people and their relatives were given opportunity to feedback on the service they were provided with and that suggestions made were implemented.

This unannounced inspection took place on 10 March 2015.

Victoria Lodge is registered to provide accommodation, nursing or personal care for up to 61 people. People using the service have conditions related to old age or dementia. At the time of our inspection 59 people were using the service.

Our inspection of September 2014 found that the provider was not meeting six of the regulations associated with the Health and Social Care Act 2008 which related to; respecting and involving people, meeting nutritional needs, safeguarding, supporting workers, staffing and assessing and monitoring the service. Following the inspection we asked the provider to take action to make improvements. The provider sent us an action plan outlining the action they had taken to make the improvements. During this inspection we looked to see if these improvements had been made and found that they had been.

The registered manager had left the service in October 2014. 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 appointed a new manager in September 2014 who told us that they were in the process of applying for registration with us, following successful completion of their probationary period with the provider.

People told us they felt confident that the service provided to them was safe and protected them from harm. We observed there were a suitable amount of staff on duty with the skills, experience and training in order to meet people’s needs.

Systems for updating and reviewing risk assessments and care plans to reflect people’s level of support needs and any potential related risks were not robust. Audits undertaken by the provider had identified that documentation in use was confusing and not fit for purpose so training for staff and implementing new documentation was planned. However, the omissions we found during our inspection had not been identified through the managers own internal auditing system.

Staff had been provided with training and were knowledgeable about how to protect people from harm. We saw that medicines management within the service was on the whole effective.

We found that staff had received the training they needed to understand and support people with their specific health needs. The provider was supportive of staff receiving additional training to develop their skills and knowledge in relation to their role.

The provider supported the rights of people subject to a Deprivation of Liberties Safeguard (DoLS). Staff were able to give an account of what this meant when supporting the person and how they complied with the terms of the authorisation.

People were supported to take an adequate amount to eat and drink. The main dining area was not conducive to people experiencing a relaxed meal time experience. Records in relation to people’s nutritional needs were not consistently updated.

The staff worked closely with a range of health and social care professionals to ensure people’s health needs were met, for example district nurses and GPs.

We observed staff interacting with people in a positive manner. People and their relatives spoke highly about the caring nature of the staff.

People told us they were encouraged to remain as independent as possible by staff. We observed staff maintain people’s privacy and dignity whilst supporting them.

People’s cultural and spiritual needs had been considered and we saw that people were supported to fulfil these.

People were involved in a range of activities of their choosing, both within the service and in the community. Planned activities were centred on people’s individual abilities and interests. During our visit we saw that people were in good spirits and meaningfully occupied.

Information about how to make a complaint was on display. The manager had responded in a timely manner to complaints received since our last inspection and in line with the provider’s policy.

People, their relatives and staff spoke about the positive impact the new manager had made since joining the service. Structures for supervision allowing staff to understand their roles and responsibilities were in place.

We saw the provider actively promoted an open culture amongst its staff and made information available to them to raise concerns or whistle blow. Staff were able to give a good account of what they would do if they learnt of or witnessed bad practice.

The manager failed to meet our requests for information which the commission uses to support the planning and gathering of evidence in relation to inspections.

We carried out an inspection on the 13 November 2013 and found that the provider was not meeting standards relating to care and welfare, nutrition and staffing. The provider wrote to us and told us what actions they were going to take to improve. During this, our latest inspection, we looked to see what actions had been taken.

We checked to see that people’s health and well-being was being promoted by the care home.

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with six people using the service, eight visiting relatives, nine members of staff, a visiting healthcare professional, the acting manager and area manager. We also looked at six records relating to people’s care and other records related to the running of the service.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

Some people told us they felt safe at the home although we saw that there were occasions where we saw people looked anxious, angry or nervous due to the challenges presented to staff by one person. We saw staff did not always know how to respond and as a result people may not have felt safe.

The provider informed us that they have responded by providing one to one staffing since our inspection, although they were aware of this risk prior to our raising it as a concern at the inspection.

People who use services were only deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the Deprivation of Liberty Safeguards (DoLS). We heard that two people had a DoLS in place and staff were aware why they were in place and what restrictions they authorised. We saw that the conditions of the DoLS were met with the exception of provision of a specific type of training for staff. The absence of this training presents a potential risk to people as some staff may not be aware of how to approach people in the least restrictive way.

The service was clean, safe and hygienic and people told us that the environment was clean. One relative told us, “This place is immaculate”.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to learning from incidents and events that affect people’s safety.

Is the service effective?

People’s health and care needs were not always assessed with them, but we heard people’s involvement in their care plans had improved. Some people were not aware of what was in their care plans but most people felt the care they received was as they wished it to be. We saw care plans had been reviewed regularly and were able to provide staff with the knowledge to meet people’s needs.

We heard from people, and saw that meals were appetising and there was a choice available. Specialist dietary needs were assessed although the support people were given with their meals did not always reflect their needs, and we saw some people were not supported or encouraged at meals times meaning they did not eat. We were also not assured that people were consistently supported to have sufficient fluids.

Visitors we spoke with confirmed that they were able to see people in private and that visiting times were flexible. One relative told us that, “Visiting welcomed, wonderful”.

People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey and were involved in meetings. There were some shortfalls, and concerns had been raised by relatives. We saw that some of these concerns had been responded to although there was some that had not. This meant that people and their representatives were at risk of not having their concerns properly taken into account.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring people at risk of malnutrition or dehydration receive sufficient food and fluids.

Is the service caring?

We saw that people were at times supported by kind and attentive staff. We saw some care workers showed patience and gave encouragement when supporting people. One relative told us, “Staff are lovely with residents”. We also saw other occasions where people’s dignity was not promoted, and one person told us they liked their bedroom door shut, but staff left it open compromising their privacy.

We asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring people’s dignity and privacy is respected, and people’s views are consistently responded to.

Is the service responsive?

We looked at the last admission to the home from another service and we found there was a lack of robust assessment prior to their readmission. As a result we found the person’s care plan was not up to date although staff were aware of these and the person confirmed these were met.

We heard from people, relatives and staff that care was not always responsive due to the insufficient availability of staff. We saw occasions where there was a slow response to people’s needs. One relative told us,” The staff are so rushed. They are struggling”. Staff we spoke with told us their availability impacted on their response to people’s needs. One member of staff told us, “Today we didn’t get everyone up until 12.30pm. Some people were left waiting a long time to get up”. This meant that staff responses to people’s needs may be delayed and their choices compromised.

We have asked the provider to tell us what improvements that will make in relation to improving staffing levels and/or staff deployment.

Is the service well-led?

This report states Mrs R Skelton is the registered manager. They were not managing regulatory activities at this location at the time of the inspection. Their names appear because they were still identified as registered manager on our register at the time.

We heard from some relatives that the managers had responded to some concerns they had raised and one told us, “The new manager is lovely, I can’t speak highly enough of her”.

Staff we spoke with were aware of who to report their concerns to and knew how to whistle blow.

The service has a quality assurance system but records seen by us showed that not all of the shortfalls identified had been addressed. Staff told us their views were not listened to, for example one told us, “I keep reporting things but nobody cares, the hoist keeps losing charge and we have few wheelchairs now”. Another told us, “I’m so stressed there is no organisation, the managers never come out”. The manager told us they were looking to talk to staff individually but the lack of confidence staff expressed in management meant that staff told us they did not feel able to provide feedback, so their views may not be properly taken into account.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance, and the improvements they will make in relation to supporting staff appropriately, so as to improve their morale.

This report states Mrs A M Bishop and Mrs R Skelton are registered managers. They were not managing regulatory activities at this location at the time of the inspection. Their names appear because they were still identified as registered managers on our register at the time.

We spoke with 10 people who lived at the home and six relatives. We observed how care was provided to people and looked at six people’s records. We spoke with five members of staff, the manager and a senior manager. We looked at other records related to the management of the home.

We saw that people were provided with care and treatment as recorded in their care plans. One person said, “Pretty decent here when there is enough staff”.

Some people told us that they had a choice of meals and were happy with the meals. Others said “There’s no real choice of food”. We saw that some people were well supported with their meals. Records did not always show they had sufficient fluids.

We saw that new staff members were vetted to ensure they were safe to work with vulnerable adults.

People we spoke with expressed satisfaction with the care and treatment they received although they were concerned that there was not always sufficient members of staff to respond to their needs quickly.

There were systems in place to monitor the quality of the service, although we identified some potential areas of risk that had not been identified. A visitor said, “We see some good work and then it slips back”.

Overall people and relatives we spoke to were happy with the care received. They were complementary about the staff saying they were lovely. However, relatives were concerned that the home was short staffed saying," they seem rushed off their feet". There were a few lapses in care which meant that people's dignity was compromised and some individual needs were not met. There were good systems in place to monitor the quality of service delivered. Improvements could be made to ensure staff feel fully supported in their roles.

We observed that people were treated with dignity and respect in a warm cheerful environment. The home organise a wide range of activities to provide a stimulating environment to live in. However, pre- admission assessments and care plans require improvement to ensure people's individual needs are met.

We inspected the home to check on improvements the provider had made following our last inspection in July 2012. We spoke with three people, five relatives and seven staff. We also spoke with the manager and area manager.

People told us that, “I have the best carers in the world”. Visiting relatives we spoke with told us, “There’s no bad thing about it (the home)” and people, “Get care that is needed”. We saw positive relationships between people and staff when they were providing support. People received appropriate support with staff showing patience and offering verbal encouragement. People received support that reflected their records. People's health care was promoted.

We found that staff's understanding as to how to protect people and report abuse had improved.

We found that systems for the management of medication had improved. This meant that people were better protected against the risks associated with medicines.

Staff showed they understood people’s needs. Staffing levels and deployment had improved with the result that people's needs were met and people were safer. Staff had been provided with additional training although there was still room for some improvement in staff training levels. The manager had recognised this and a programme of training and retraining was in place.

The ways in which feedback from people and their representatives was obtained had improved. Better outcomes for people showed that monitoring of quality had improved.