CQC report explained · a residential care home
What the CQC found at Victoria House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. Fire door work had been completed, risks were monitored, medicines were managed safely and there were enough staff to support people safely.
- Effective?
- Good
- This key question was not inspected during this visit, so no new rating was given in the report.
- Caring?
- Good
- This key question was not inspected during this visit, so no new rating was given in the report.
- Responsive?
- Good
- People's care, communication, activities and rehabilitation were arranged around their needs and preferences. Inspectors found that specialist therapy support had improved since the previous inspection.
- Well-led?
- Good
- Inspectors found more stable leadership, improved communication and effective systems for monitoring quality, risks and improvement.
What inspectors found, November 2023
Rated Good; inspectors found safer care, better rehabilitation support and stronger management after the previous Requires Improvement rating.
Inspectors visited the home without notice on 11 July 2023. They spoke with 10 people, three relatives and six staff. They observed care and therapy sessions and checked care plans, medicines, fire safety, recruitment and management records.
The home was rated Good overall. Safe, Responsive and Well-led were each rated Good. Inspectors found improvements had been made and sustained since the previous inspection, including better fire safety, enough specialist staff for rehabilitation and more stable management.
People were supported with personal care, daily activities and therapies. Inspectors found effective systems for managing risks, medicines, safeguarding, infection control, complaints and learning from incidents.
This was not a full inspection of all five key questions. For questions not inspected, the previous ratings were used to calculate the overall rating.
Specialist rehabilitation
The home had the specialist staff needed to provide a fuller rehabilitation service, including occupational therapy, physiotherapy, psychology and neurological speech and language therapy.
“These included occupational therapists, physiotherapists, psychologists and a neurological speech and language therapist.” from the report
Risk management
Individual risks, including falls, pressure injuries and seizures, were assessed and reviewed regularly. Fire safety improvements identified at the previous inspection had been completed.
“The provider had maintained an effective system to identify, assess, monitor and manage individual risks arising from people's conditions and choices.” from the report
Personalised support
Therapy and daily care reflected people's needs, choices and communication preferences. People were supported to take part in activities and maintain contact with family.
“Our observations and discussions with staff showed people's therapy sessions were arranged to meet their needs, respected their choices, and were in line with current standards and good practice.” from the report
Stronger leadership
Inspectors found greater stability, better communication and improvements that had been maintained since the previous inspection.
“The registered manager had introduced a period of stability, which had improved staff morale, and communications with staff, people who used the service, and their families.” from the report
Learning from incidents
The home recorded and reviewed accidents, incidents and near misses. Learning was shared with staff and used to reduce the risk of harm happening again.
“The provider continued to operate an effective online system to learn from incidents, accidents and near misses.” from the report
Fire door certification
minorThe necessary fire door work had been completed, but at the time of the inspection the provider was still seeking checks and certification. Families may want to confirm that this was completed.
“At this inspection, the necessary works had been completed and the provider was seeking to have the fire doors checked and certified.” from the report
Continued recruitment
minorThere were enough staff to support people safely, and reliance on agency staff had reduced. However, the provider was still recruiting, so families should ask how staffing levels and specialist cover are maintained.
“The provider had reduced their dependency on agency staff and continued to recruit.” from the report
- 01Have the fire doors now been checked and certified, and can you show us the latest records?
- 02Which rehabilitation specialists will support my relative, and how often will therapy sessions take place?
- 03How do you make sure there are enough suitably skilled staff when agency staff are needed?
- 04How will you measure and review my relative's personal rehabilitation goals and progress?
- 05How will families be kept informed about the service improvement plan and any further changes?
This was a focused inspection covering Safe, Responsive and Well-led; the other key question ratings were not inspected during this visit and previous ratings were used to calculate the overall rating. This explanation was written from the published report of 9 November 2023 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.
What inspectors found, July 2022
Rated Requires Improvement; inspectors found kind care and safe medicines, but fire safety, rehabilitation therapy and leadership needed improvement.
Inspectors made an unannounced visit on 10 and 11 May 2022. They spoke with people, a relative and staff, watched care and therapy, and checked care records, fire safety, medicines and recruitment records.
People generally described the home positively. Staff supported people with personal care, daily activities and communication. Meals were well regarded, medicines were managed safely, and people were treated with kindness, dignity and respect.
There were important shortfalls. Some fire doors had not been improved, and there were not enough in-house specialists to provide the rehabilitation therapy people needed. Care did not always include planned therapy, and a period of inconsistent leadership had affected staff morale and people's outcomes.
The overall rating was Requires Improvement. Safe, Responsive and Well-led were also rated Requires Improvement. Effective and Caring remained Good. The previous overall rating was Good, but the provider had changed since that inspection.
Kind and respectful care
People were supported with kindness and compassion. Staff respected privacy, dignity and independence, and helped people communicate and make everyday choices.
“We saw caring, positive interactions between staff and people they supported.” from the report
Medicines were managed safely
People received medicines at the right time from trained staff. Storage, records and regular checks were in place.
“People received their medicines safely and in line with good practice standards.” from the report
Good food and choice
People and families spoke highly of the meals and choice. Staff adapted food to individual nutrition needs and preferences.
“People and their families were very complimentary about the quality of meals and choice available.” from the report
Support with activities and relationships
Staff helped people avoid isolation, make social contacts and take part in activities they valued, including activities outside the home after restrictions eased.
“People took part in activities that were important and interesting to them.” from the report
Fire safety work was unfinished
seriousA fire risk assessment had identified improvements to some fire doors, but these had not been completed. Inspectors said people remained at increased risk if smoke spread during a fire.
“People continued to be at increased risk from smoke spreading in the event of a fire.” from the report
Not enough rehabilitation specialists
needs fixingThere were no qualified therapists on site and no trained occupational therapists or psychologists. Inspectors said this could delay rehabilitation and a return to more independent living.
“There were no qualified therapists on site.” from the report
Planned therapy was not always delivered
needs fixingOne care file showed no record that assessed physiotherapy or occupational therapy had been provided for three months. A relative also reported that needed physiotherapy was inconsistent.
“There were no records to show their therapy had been delivered for three months before our visit.” from the report
Leadership and communication needed improvement
needs fixingA period of inconsistent leadership affected staff morale and meant information about people's care needs was not always communicated. The new manager's improvements had not yet been embedded and sustained.
“During a period of inconsistent leadership people's experience and staff morale had suffered.” from the report
- 01What has been done to improve the fire doors identified in the August 2021 fire risk assessment, and how is the risk being managed until the work is complete?
- 02Which rehabilitation specialists are now available, and how will you make sure each person's assessed physiotherapy and occupational therapy is delivered and recorded?
- 03What changes has the new manager made to improve communication about people's care needs?
- 04How will you show that the quality improvement plan is being completed, funded and sustained?
- 05What is the current position on the manager's application to register with CQC?
This was an unannounced inspection covering all five key questions and infection prevention and control, with the previous ratings used to inform the new assessment. This explanation was written from the published report of 7 July 2022 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 House
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- November 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2022Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- December 2020Inspected but not ratedSafe: Inspected but not rated
- October 2020
Registered with the Care Quality Commission on 2 October 2020.
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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