CQC report explained · a residential care home
What the CQC found at Victoria Hall
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm, with risk assessments, suitable equipment and enough staff. Medicine charts were not all up to date, and there were some omissions.
- Effective?
- Good
- Staff had induction, training and supervision. People's care plans, food and drink, health needs and choices were generally well supported.
- Caring?
- Good
- People and relatives described staff as kind, caring and respectful. Staff supported privacy, independence, communication and relationships.
- Responsive?
- Good
- Care plans were personalised and reviewed. Relatives gave mixed feedback about being involved in care planning, and activities received mixed responses.
- Well-led?
- Requires improvement
- The manager was working on improvements, and audits identified areas for action. However, legionella testing arrangements did not follow recommended guidance and relatives reported inconsistent communication.
What inspectors found, November 2021
Rated Good overall; inspectors found kind, safe care, but leadership and record-keeping needed improvement.
Inspectors visited without notice on 27 September and 12 October 2021. They spoke with five people, six staff members and 11 relatives. They also reviewed care, medicine, recruitment, training and management records.
People generally felt safe and said staff were kind, respectful and caring. Staff understood people's needs, supported their health and medicines, and helped them keep in touch with relatives. Infection control arrangements were mostly suitable, although one mask-use risk assessment was missing.
The home was rated Good for Safe, Effective, Caring and Responsive. It was rated Requires Improvement for Well-led. Inspectors found some medicine records were incomplete, communication with relatives was inconsistent, and legionella testing arrangements did not follow the recommended guidance.
Kind and respectful staff
People and relatives said staff were caring, patient and respectful. Inspectors also observed kind and reassuring interactions.
“People were supported by staff who treated them with patience, kindness and understanding.” from the report
Enough staff
Inspectors found there were enough staff to meet people's needs. The home did not use agency staff so people could receive familiar support.
“There were enough staff on duty to meet people's needs.” from the report
Personalised care
Care plans included people's histories, preferences and communication needs. Staff knew what mattered to people and supported their independence.
“Care plans were personalised and contained information about people's history and personal preferences.” from the report
Staff training and support
New staff received induction and role-specific training. Staff also had regular supervision and said managers were approachable.
“Staff stated they completed a period of induction training.” from the report
Medicine records
needs fixingSome medicine administration charts were not up to date and contained omissions. The manager said this would be addressed immediately.
“We found not all medication administration charts (MARS) were up to date and there were some omissions.” from the report
Legionella testing
seriousThe provider's policy did not include the recommended testing arrangements, and testing had not been carried out as advised by the Health and Safety Executive.
“This provider had not carried out any testing as recommended by the Health & Safety Executive.” from the report
Communication with relatives
needs fixingSome relatives said they were not kept up to date about their family member's needs or changes in care. The manager said action would be taken.
“I would like more contact to be informed not only just when [family member] has an accident.” from the report
Activities
minorPeople gave mixed feedback about activities. The manager said activities would be reviewed and people would be consulted.
“Pop in to see me, but there is nothing I enjoy,” from the report
- 01What changes have been made to ensure all medicine administration charts are complete and up to date?
- 02What legionella testing has been carried out since the inspection, and how is this now recorded?
- 03How will you keep relatives informed about changes in care, needs and incidents?
- 04What activities are now available, and how are residents involved in choosing them?
- 05What risk assessment is now in place for staff using the required protective masks?
This was an unannounced inspection covering all five CQC questions, including infection prevention and control; it was the first inspection under the provider's new legal registration. This explanation was written from the published report of 16 November 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Victoria Hall
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- November 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2018Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2019
Registered with the Care Quality Commission on 1 May 2019.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.