CQC report explained · a residential care home
What the CQC found at Victoria Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Staff understood safeguarding, risks were assessed, medicines were administered safely, there were enough staff and infection control measures were in place.
- Effective?
- Good
- This question was not inspected during this focused visit. Its rating was carried over from the previous inspection when calculating the overall rating.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People were involved in decisions about their care and were supported to remain as independent as possible.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its rating was carried over from the previous inspection when calculating the overall rating.
- Well-led?
- Good
- Management understood its regulatory responsibilities, used audits and action plans, and involved people, relatives and staff. This rating improved from Requires Improvement at the previous inspection.
What inspectors found, June 2022
Rated Good; inspectors found safe, kind and well-managed care, after reviewing safeguarding concerns.
This was an unannounced focused inspection. Inspectors visited on 9 May 2022 and reviewed Safe, Caring and Well-led. They spoke with people, relatives, staff and healthcare professionals, observed care and checked care, medicine, staffing and management records.
The home was rated Good overall. Safe, Caring and Well-led were also rated Good. People said they felt safe, staff were kind and respectful, medicines were given safely, and relatives were kept informed.
The inspection followed safeguarding concerns. Inspectors found no evidence that people were at risk of harm from those concerns. They found suitable safeguarding systems, enough staff, good infection control and improvements in management since the previous inspection.
Safe medicines
Staff who gave medicines had been trained and assessed as competent. Records and storage were in line with current guidance.
“People were administered their medicines safely by trained staff who were assessed as competent to do so.” from the report
Good communication
People and relatives were involved in care planning and reviews. Staff adapted communication for a person who had difficulty hearing.
“Staff spent time to write conversations down, rather than just questions with yes or no answers.” from the report
Working with health professionals
The home made referrals when needed and worked with health professionals, including falls, dementia and speech and language services.
“Staff worked with a variety of professionals to include district nurses, the dementia crisis team, GPs, speech and language therapists (SaLT) and the falls team.” from the report
Management improvements
Management had improved its oversight since the previous inspection. It acted on audits, updated records and addressed identified issues.
“At this inspection the registered manager understood their duty to notify CQC of events within the service, records confirmed this had been done appropriately.” from the report
Safeguarding concerns prompted the inspection
minorThe inspection followed concerns about safeguarding matters. Inspectors found no evidence that people were at risk of harm from these concerns, and found safeguarding systems in place.
“We received concerns in relation to safeguarding matters which had been raised.” from the report
- 01What safeguarding concerns have been raised recently, and what actions were taken in response?
- 02How will you assess whether staffing levels are enough for my relative, including if they need one-to-one support?
- 03How will you manage my relative's medicines, including any medicines needed only when required or given covertly?
- 04How will my relative and our family be involved in care planning and regular reviews?
- 05How do staff record and share changes in my relative's needs during handovers?
This was a focused inspection of Safe, Caring and Well-led only; the other question ratings were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 10 June 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.
What inspectors found, February 2019
Victoria Lodge is rated Good overall, but inspectors found that leadership checks, some legal notifications and medicines records needed improvement.
This was an unannounced, comprehensive inspection on 18 and 23 May 2018. Inspectors spoke with people living at the home, a relative and staff. They observed care and medicines being given, and checked care records, medicines records, staff files, audits, complaints and other documents.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found kind staff, suitable care plans, safe recruitment, clean surroundings, support with food and healthcare, and activities for people. Staff training had improved since the previous inspection.
Well-led was rated Requires Improvement. The home had not always sent required notifications to the CQC, including notifications about Deprivation of Liberty Safeguards and a diarrhoea and vomiting outbreak. Medicines records and quality checks were not always completed accurately or effective enough to identify problems.
Kind and respectful care
Inspectors saw staff treating people with patience, reassurance, dignity and respect. Staff knew people well and involved them in everyday choices.
“People were looked after by kind and caring staff who knew them well.” from the report
Personalised care plans
Care plans gave staff detailed information about people's needs, health, medicines, histories, likes and dislikes.
“Care plans were detailed and written in a person-centred way.” from the report
Improved staff training
The home had made improvements since the previous inspection in staff training and support. Staff had completed training in several relevant areas and were encouraged to gain qualifications.
“Improvements had been made with regard to staff completing a range of training.” from the report
Food and healthcare
Menus reflected people's dietary needs, likes and dislikes. People had drinks available and access to a range of healthcare professionals.
“Menus for people were planned in line with their dietary needs, likes and dislikes.” from the report
Required notifications were delayed or missed
seriousThe provider did not notify the CQC promptly about Deprivation of Liberty Safeguards authorisations and did not notify it about a 2017 diarrhoea and vomiting outbreak.
“The provider had failed to notify the Commission of Deprivation of Liberty Safeguards authorisations and of a diarrhoea and vomiting outbreak in 2017, which they were required to do.” from the report
Medicines records were not always checked
seriousAt least three handwritten medicines records had not been checked and witnessed by a second trained staff member. The provider took immediate action, but the issue had not been identified by its own checks.
“At least three MARs, which recorded the medicines people had been prescribed, had been hand-written by a member of staff.” from the report
Management checks needed strengthening
needs fixingAudits did not always identify problems with medicines records or accidents and incidents. The report said the new quality systems needed to become established in everyday practice.
“Quality assurance systems had not always been effective in identifying issues.” from the report
Supervision was not regular enough
needs fixingSome staff had not received supervision as often as the home's policy required. Records also did not always show how outstanding actions had been followed up.
“Staff records we looked at showed that staff had not received regular supervisions in line with this policy.” from the report
- 01How do you now make sure Deprivation of Liberty Safeguards authorisations are notified to the CQC on time?
- 02How are handwritten medicines administration records checked and signed before they are used?
- 03How often will staff receive supervision, and how are actions from previous meetings followed up?
- 04What one-to-one and group activities are now available, especially for people who stay in their rooms?
- 05How do your audits identify and act on medicines errors, accidents and incidents?
This was an unannounced comprehensive inspection covering all five key questions, with the premises and care provided both looked at. This explanation was written from the published report of 9 February 2019 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 Lodge
3 rated inspections over 6 years: the service has held its Good rating throughout.
- June 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2019Goodstayed GoodSafe: GoodCaring: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 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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