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
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe recruitment, safe medicines management and appropriate action after incidents, although some risk and injury records needed improvement.
- Effective?
- Good
- People's needs were assessed and staff had suitable knowledge and training. People received support with food, drinks and healthcare, but some mental capacity decisions were not fully assessed or recorded.
- Caring?
- Good
- People were treated with kindness, dignity and respect. They were involved in care planning and could make choices about their daily routines and support.
- Responsive?
- Good
- Care was personalised and staff knew people's preferences and communication needs. Activities were available, but opportunities to go out were limited unless people went with relatives.
- Well-led?
- Requires improvement
- The home had a positive culture and approachable management, but quality checks did not always identify problems. Records about allergies, diabetes risks and mental capacity were inconsistent.
What inspectors found, January 2023
Rated Good overall, but inspectors found the home was not always well-led and its records needed improvement.
Inspectors visited unannounced on 6 and 9 December 2022. They spoke with people, relatives and staff, checked care and staff records, and reviewed medicines, staffing, incidents and management audits.
The home was rated Good for safe, effective, caring and responsive care. People were generally safe, treated kindly and respectfully, and supported with their health, meals, choices, communication and activities. Medicines were managed safely and there were enough staff to meet people's needs.
Well-led was rated Requires Improvement. Inspectors found gaps and inconsistencies in records, including allergy information, diabetes risks and decisions made under the Mental Capacity Act. Some key decisions were not fully recorded. The home took immediate action on several issues, but its checking systems had not found all the problems.
Kind and respectful care
People told inspectors they were treated well. Staff were observed speaking warmly, protecting privacy and supporting people's dignity.
“We observed staff interacting with people in a friendly and supportive way.” from the report
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and robust recruitment checks. Medicines were stored, administered and recorded safely.
“Medicines were stored and administered safely.” from the report
Personalised support
Care plans recorded people's choices, preferences and communication needs. Staff used handheld devices to access current care information.
“This meant people received care which was tailored to their needs and wishes.” from the report
Good health and nutrition support
People received suitable food and drink support, including modified diets where needed. The home worked with health professionals and responded to people's healthcare needs.
“People's healthcare needs were met in a timely and effective way.” from the report
Quality checks missed problems
needs fixingThe home's monitoring systems did not consistently identify errors or gaps in important records. The manager took action when inspectors raised issues, but the systems needed to become more reliable.
“Systems in place to monitor the quality and standards of the service were not always effective.” from the report
Mental capacity records
needs fixingSome important decisions did not have separate assessments, and records did not always show who had been involved in best-interest decisions. This created a risk that legal principles were not consistently followed.
“We found some key decisions did not have separate MCA assessments” from the report
Dementia environment
needs fixingThe dementia wing needed improvements to its décor and design. Inspectors recommended using best-practice guidance, and the provider started work during the inspection.
“The environment could be improved, and we recommended the provider seek best practice guidance on dementia friendly environments.” from the report
Limited trips out
minorPeople had limited chances to go on outings because the home lacked transport and staff able to drive the bus. The home did provide activities inside.
“Opportunities for people to go out and about were limited unless they went with a relative.” from the report
Staff injuries not always reported
needs fixingSome injuries to staff were not reported. This meant managers might not have had all the information needed to understand distressed behaviour and reduce future risks.
“Sometimes staff received an injury such as bruising to their hand caused by a person whilst they were distressed.” from the report
- 01What checks are now in place to make sure allergy, diabetes and mental capacity records are complete and consistent?
- 02How will you record who was involved in best-interest decisions for people who lack capacity?
- 03What improvements have been made to the dementia wing since the inspection?
- 04How are staff injuries and distressed behaviour now reported, reviewed and used to update support plans?
- 05What is the current plan for providing more trips outside the home?
This unannounced inspection looked at all five CQC questions, with particular attention to staffing concerns; all five ratings were reviewed and the previous overall rating was Good. This explanation was written from the published report of 20 January 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, December 2018
Victoria House is rated Good; inspectors found safe, kind and personalised care across all five areas.
This was an unannounced inspection on 28 November 2018. One inspector, an assistant inspector and an expert by experience visited the home. They spoke with people, relatives and staff, observed care, checked records, toured the premises and reviewed recruitment, medicines and quality checks.
Inspectors found that people were safe and that there were enough staff. Medicines, infection control and risks were managed appropriately. Staff had suitable training and supported people's health, nutrition, choices and independence.
People were treated with kindness, dignity and respect. Care plans reflected people's preferences, activities were tailored to their interests and people could give feedback or make complaints. The home was well managed, with audits and feedback used to improve care.
The home was rated Good in every area: Safe, Effective, Caring, Responsive and Well-led. This was the same overall rating as the previous inspection, published on 13 July 2016.
Enough staff
People and relatives said staff were available, and inspectors observed enough staff on shift to support people safely.
“We observed sufficient numbers of staff on shift to support people safely.” from the report
Kind and respectful care
Inspectors found positive relationships between staff and people. Staff understood people's needs and supported their dignity and choices.
“People were cared for by staff who were kind, caring and compassionate.” from the report
Personalised care
Care plans included people's histories, preferences, interests and aspirations. Activities were adapted to people's individual interests.
“As part of the pre-admission process, people and their relatives were involved to ensure that staff had a good insight into people's personal history, their individual preferences, interests and aspirations.” from the report
Safe medicines management
Staff were trained and assessed in medicines administration. Records and audits supported safe and timely medicines management.
“People continued to receive their medicines as prescribed.” from the report
Strong management checks
The provider and registered manager used regular audits and feedback to identify actions and improve the service.
“Effective systems were in place to monitor and improve the quality of the service provided through a range of internal checks and audits.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you adapt care and activities to my relative's history, preferences, interests and aspirations?
- 02What current staffing levels are in place, and how do you make sure there are enough staff to meet people's needs safely?
- 03How will you support my relative's dietary needs and arrange appointments with healthcare professionals?
- 04How do you involve people and relatives in care decisions, reviews and feedback?
- 05What support is available if my relative needs end of life care?
This was an unannounced comprehensive inspection covering all five areas, with care and premises both looked at. This explanation was written from the published report of 28 December 2018 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
5 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- January 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 17 December 2010.
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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