CQC report explained · a nursing 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 by safeguarding systems, risk assessments, safe recruitment, enough staff and safe medicines management. Inspectors found hoist slings being shared, but the registered manager later said they had been labelled and allocated to individuals.
- Effective?
- Requires improvement
- Staff did not have the full range of training needed for their roles. Some clinical training could not be evidenced, and parts of the building, signage and room arrangements did not fully meet people's needs.
- Caring?
- Good
- No separate Caring rating was given in this report. Inspectors observed respectful care, and people said staff respected their privacy and dignity.
- Responsive?
- Good
- No separate Responsive rating was given in this report. Care plans included people's communication, religious, cultural and end of life needs, and people were supported to receive visitors.
- Well-led?
- Good
- Inspectors found clear leadership, regular audits, an open culture and systems for people, relatives and staff to give feedback. The management team had oversight of quality and safety.
What inspectors found, March 2023
Rated Good; inspectors found safe, kind care, but staff training and parts of the home needed improvement.
Inspectors visited without notice on 23 February 2023. They spoke with people, relatives, staff and a visiting vicar. They reviewed care records, medicines records and management records, and observed care.
The home was rated Good overall. Safe and well-led were rated Good. People told inspectors they felt safe, staff were kind, medicines were managed safely, and there were enough staff. Care plans reflected people's needs and choices, and healthcare professionals were involved when needed.
Effective was rated Requires Improvement, as staff training was not complete in line with the Care Certificate and some clinical training could not be evidenced. Some parts of the building also needed refurbishment, better signs for people living with dementia and more personalised rooms.
The previous overall rating was Requires Improvement, published on 1 July 2021. The overall rating changed to Good. Well-led improved from Requires Improvement to Good, while Safe stayed Good and Effective stayed Requires Improvement. The provider was recommended to review staff training.
Medicines managed safely
People received medicines as prescribed. Nursing staff had medicines training and competency checks, and regular audits were completed.
“Medicines were safely managed, and people received their medicines as prescribed.” from the report
Respectful, person-centred care
Care plans reflected people's needs and choices. Inspectors saw staff offering choices and people said staff respected their dignity and privacy.
“People told us staff treated them with dignity and respect, and they made choices, such as when they got up and went to bed.” from the report
Open leadership
People, relatives and staff described the home as approachable and well led. Audits and management visits were used to monitor quality.
“The registered manager promoted an open and honest culture in the service.” from the report
Incomplete staff training
needs fixingNot all Care Certificate training had been completed. The provider also could not evidence initial clinical skills training for nursing staff, although training was later said to be booked.
“Whilst some areas of the Care Certificate were covered, not all areas had been completed.” from the report
Environment needed improvement
needs fixingSome areas were tired, with stained furniture and carpets. Some rooms were not personalised, some people shared rooms, and signs to help people living with dementia were missing.
“Some areas of the service were tired and in need of redecoration and some furniture and carpets were stained.” from the report
Shared hoist slings
seriousHoist slings were being used generically. Inspectors said this could create a cross-contamination or moving and handling risk. The registered manager later gave assurances that this had been corrected.
“During the inspection hoist slings were found to be used generically, which could place people at risk of cross contamination or unsafe moving and handling.” from the report
Infection control during an outbreak
needs fixingDuring a COVID-19 outbreak, one staff member answered the door without a mask and other staff wore jewellery. The manager said this would be monitored more closely.
“The service had a Covid-19 outbreak at the time of inspection and 1 staff was observed to answer the door without a mask” from the report
- 01Has all Care Certificate training now been completed for the staff team, and how is this checked?
- 02Can you show how nursing staff's initial clinical skills training and competency checks are recorded?
- 03Are all hoist slings now labelled and allocated to individual people?
- 04What work has been completed on refurbishment, stained furniture and carpets, and what remains on the improvement plan?
- 05How do you make the home easier to navigate for people living with dementia, and how are decisions about shared rooms made?
This was an unannounced inspection covering Safe, Effective and Well-led, with infection prevention and control also checked; ratings for key questions not inspected carried over from the previous comprehensive inspection. This explanation was written from the published report of 7 March 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 2021
Rated Requires Improvement; inspectors found safe care, but records and oversight were not always reliable.
This was an unannounced focused inspection on 4 June 2021. One inspector spoke with two people, six staff members and reviewed care, medicines and management records. Infection prevention and control was also checked because of COVID-19 risks.
The home was rated Good for Safe. People said they felt safe. Inspectors found enough staff, safe medicines practices, suitable safeguarding arrangements and appropriate infection control measures. They found staff understood people's risks and used protective equipment properly.
The home was rated Requires Improvement for Well-led. Some care records were incomplete or inaccurate, and audits had not always identified problems or led to timely action. The overall rating changed from Good to Requires Improvement because of these findings.
The other three key questions were not inspected during this visit. Their previous ratings were used when calculating the overall rating.
People felt safe
People told inspectors they felt safe, and staff knew how to recognise and report possible abuse.
“People told us they felt safe living at Victoria House.” from the report
Enough staff
Inspectors found staffing levels were enough to meet people's needs safely and promptly. Recruitment checks were also carried out.
“There were enough staff to care for people safely and the feedback from staff and people living at the home was current staffing levels were sufficient.” from the report
Infection control
Staff were observed wearing appropriate protective equipment. The home had infection control procedures, testing arrangements and hand-washing facilities.
“We observed staff wearing appropriate PPE through the home.” from the report
Positive culture
Staff described a supportive and close team. People said the management team was approachable and staff listened to how they wanted their care delivered.
“The management team and provider promoted a positive culture within the home.” from the report
Care records were incomplete
needs fixingSome records did not contain information that should have been recorded, including required weight records and personal details such as interests and life history.
“We found records were not always accurate. Care plan records did not always include relevant information” from the report
Audits did not find or fix all issues
needs fixingAudits had not identified some problems, and actions from an earlier care-plan audit were still incomplete at the inspection.
“However, care plan audits carried out by the regional manager in February 2021 identified areas of the care plans which required completion such as, interests and life history.” from the report
Conflicting care records
needs fixingOne care plan said a person should not be given bread or sandwiches, but daily records showed sandwiches had been given. Inspectors found no evidence of harm, but this raised concerns about the accuracy of records and oversight.
“some daily record entries in 2020 showed the person had been given sandwiches for their meal.” from the report
Some medicines records needed improvement
needs fixingInspectors found no body map for one cream and handwritten medicine records without two signatures. They found no evidence that anyone had been harmed.
“Where issues were identified such as, no body map for the application of creamed medication and handwritten MAR's without two signatures, we found no evidence people had been harmed.” from the report
- 01What has been done to make sure care plans are complete, accurate and updated promptly?
- 02How do you now check that audit actions are completed on time?
- 03How do you prevent care records from giving conflicting instructions about food and other care?
- 04What checks are now in place for cream application records and handwritten medicine records?
- 05What improvement plan is being followed after the Well-led rating changed from Good to Requires Improvement?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 3 July 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 House
7 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2021Requires improvementdown from GoodSafe: GoodWell-led: Requires improvement
- February 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Good
- April 2018Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- December 2011
Registered with the Care Quality Commission on 13 December 2011.
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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