CQC report explained · a residential care home
What the CQC found at Victory Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risks were assessed, medicines were managed safely, there were enough staff, and infection control procedures were followed, although a few medicines administration record gaps were found and corrected.
- Effective?
- Good
- People's needs were assessed and reviewed. Staff had relevant training and supervision, people were supported to eat and drink enough, and staff worked with health and social care professionals.
- Caring?
- Good
- Staff were kind and compassionate and treated people with dignity and respect. People and relatives were involved in decisions, and people were encouraged to remain as independent as possible.
- Responsive?
- Good
- Care was personalised and reflected people's routines, communication needs, interests, cultural and religious needs. The activity coordinator post was vacant, but care staff arranged group and one-to-one activities.
- Well-led?
- Good
- The home had visible management, regular audits, meetings and feedback systems. The provider used reviews and action plans to identify and address shortfalls.
What inspectors found, December 2019
Rated Good; inspectors found kind, safe and personalised care, with a few medicines recording gaps corrected during the inspection.
This was an unannounced inspection on 22 and 25 October 2019. Inspectors reviewed care and staff records, quality checks, incidents and health and safety information. They spoke with eight people using the service, three relatives and five care staff, and observed care in communal areas.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines management, suitable training, good support with food and drink, and proper involvement in decisions about care.
People were treated with kindness, dignity and respect. Care plans reflected people's needs and preferences. The home supported activities, family contact, communication needs and end of life wishes.
There were a few gaps on medicines administration records, although the daily records showed the medicines had been given and the issue was corrected by the second inspection day. The activity coordinator post was vacant, but care staff were providing activities.
Kind and respectful care
Inspectors saw warm relationships between staff and people. Staff offered reassurance, used preferred names and respected privacy.
“People were treated with kindness and compassion.” from the report
Personalised support
Care plans included people's health, background, preferences and routines. Staff adapted support to individual needs and encouraged independence.
“People received care to meet their individual needs and requirements.” from the report
Safe staffing and risk management
Inspectors found enough staff to meet people's needs, with risk plans and safety checks in place. Recruitment checks were also completed before staff started work.
“There were enough staff available to support people with their needs.” from the report
Good support with food and drink
People were offered choices, snacks and drinks, with extra help when needed. Hydration stations were available around the home.
“People's nutritional and hydration needs were met.” from the report
Good involvement and leadership
People, relatives and staff were asked for their views. Management used audits, meetings and action plans to monitor and improve the service.
“The quality of the home was regularly assessed and monitored.” from the report
Medicine records
needs fixingInspectors found a few gaps in medicine administration records. Other daily records and stock checks indicated the medicines had been given, and the records were corrected by the second inspection day.
“We noted a few gaps on the MAR but when we checked the daily record we saw that they were logged as administered.” from the report
Staff could sometimes feel rushed
minorStaff said staffing was usually enough but could be stretched when someone cancelled a shift. The report says people were not put at risk and bank staff were available.
“We are enough most of the time, but we can be rushed sometimes if a staff cancels their shift.” from the report
Activity coordinator vacancy
minorThe activity coordinator post was vacant during the inspection. Care staff were arranging activities in groups and on a one-to-one basis instead.
“At the time of our inspection, the position of activity coordinator was vacant.” from the report
- 01Have the medicine administration record checks been strengthened since inspectors found a few gaps?
- 02How do you maintain staffing levels when a member of staff cancels a shift?
- 03Has the activity coordinator vacancy been filled, and who now plans and delivers activities?
- 04How are relatives involved in best-interests decisions when a person cannot make a specific decision?
- 05How do you make sure care plans are updated when people's needs change?
This was an unannounced inspection covering all five key questions, including the care provided and the premises; the previous overall rating was Good and remained Good. This explanation was written from the published report of 7 December 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.
What inspectors found, April 2017
Victory Care Home was rated Good; inspectors found safe, kind and personalised care while extensive building work was under way.
This was an unannounced comprehensive inspection on 20 March 2017. Inspectors spoke with 12 people living in the home, five relatives and staff. They observed care and checked care files, medicines records, staff records, training, complaints and quality checks.
The home supported 50 people, all living with dementia, and was registered for 52 people. Inspectors found that people were protected from abuse, medicines were managed safely, risks were assessed and care plans gave staff detailed guidance.
People were supported with food, drink, health care and personal choices. Staff were described as kind and respectful. Inspectors also found a range of activities, regular care plan reviews and good involvement from families.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The home had also been rated Good in all areas at the previous inspection on 19 March 2015.
Detailed care planning
Care plans described people's individual support needs, risks, communication and interests. People and their families were involved in developing and reviewing them.
“People had a comprehensive care plan that provided detail of the individual support they required.” from the report
Kind and respectful staff
Inspectors observed calm and patient care. Staff knew people well and supported their privacy, dignity and independence.
“Staff were seen to be calm and patient, reassuring people when they were anxious or were feeling lost.” from the report
Safe medicines support
Medicines were given by trained staff and records and guidance were kept up to date, including for medicines taken only when needed.
“People continued to receive their medicines as prescribed, from staff that were suitably trained.” from the report
Food and activities
People were offered food choices and support with nutrition. Inspectors found a varied activity programme, including music, exercises, quizzes and personal time.
“There continued to be a range of activities to appeal to people's differing wishes and needs.” from the report
Strong quality checks
Managers carried out regular audits and used complaints, accidents and feedback to identify improvements. An independent audit was also completed every three months.
“The provider continued to understand the principles of good quality assurance and had a process in place to check the quality and safety of the service.” from the report
Inspectors raised no specific concerns in this report.
- 01Has the extensive refurbishment now been completed, and what changes should residents and families expect?
- 02How will staffing levels be maintained if the home expands by nine bedrooms?
- 03How are my relative's care plan and risk assessments reviewed when their needs or behaviour change?
- 04How will my relative be supported to choose activities, food and daily routines if they do not want to join in?
- 05How can families see the results of recent quality audits and raise concerns?
This was an unannounced comprehensive inspection covering all five areas, and the ratings remained Good from the previous inspection. This explanation was written from the published report of 26 April 2017 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 Victory Care Home
3 rated inspections over 4 years: the service has held its Good rating throughout.
- December 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- September 2013
Registered with the Care Quality Commission on 4 September 2013.
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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