Victory SocialCare Enterprise was rated Requires Improvement overall at its first inspection, with breaches of Regulation 17 (Good Governance) and Regulation 18 (Staffing) due to inadequate training, supervision, medicines oversight and record keeping. Despite these shortfalls, people received person-centred, kind and responsive care, with positive feedback from people and relatives.
Concerns (9)
critical
Governance
: “The provider failed to operate effective governance systems to ensure the safety and quality of the service.”
criticalRecord keeping: “The provider had failed to ensure good standards of record keeping.”
criticalStaff training: “Staff training was out of date and some staff had not completed their initial compulsory training.”
criticalSupervision / appraisal: “Staff did not receive regular supervision to ensure they received appropriate support within their roles.”
criticalStaff competency: “The provider had failed to ensure that staff were skilled, trained and competent to perform their roles.”
moderateMedication management: “Audits carried out had not been recorded to help monitor and make sure medicines were managed safely.”
moderateSafeguarding: “All staff had not completed their safeguarding training and some refresher training was out of date.”
moderateIncident learning: “This meant opportunities to learn lessons when things go wrong may have been missed.”
minorOther: “interview records and references were not consistently recorded to ensure a robust recruitment system was in place.”
Strengths
· People received person centred care and relatives spoke positively about the care and the registered manager.
· Staff developed and implemented individualised risk assessments which mitigated risks to people's safety and wellbeing.
· Care plans covered all aspects of people's lives and their preferences.
· Staff respected people's privacy and dignity and promoted their independence.
· Good infection prevention and control practices including effective use of PPE.
Quality-Statement breakdown (19)
safe: Staffing and recruitmentNot rated
safe: Using medicines safely; Learning lessons when things go wrongNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Preventing and controlling infectionNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering; Duty of candour; Working in partnership with othersNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated