New Victoria Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

However, the service was previously in breach of legal regulation in relation to the governance at the service . The provider remains in breach of this regulation. Some records related to people and the management of the service were not consistently maintained.

The service was previously in breach of legal regulation in relation in relation to Safe care and treatment as care plans were not always accurate and complete. The provider remains in breach related to safe care and treatment. See the Safe key question.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff told us they felt supported and involved in improving the service and they considered they worked well as a team. The registered manager supported staff to understand the aim of the service, which was to deliver good care which met people’s needs and promoted their rights.

Staff told us the registered manager spent time with them sharing information on best practice either in scheduled meetings or within additional meetings or ‘huddles’ which happened when the registered manager had updates, feedback or concerns to share with the team. One staff member told us, “[Registered manager,] she is good, you can talk to her .”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

All the staff we spoke with felt supported by the registered manager. A staff member commented, “[Registered manager] is excellent, I can’t fault her. Her door is always open, and she will sit and listen and try and give advice.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Before this assessment we received some concerns about the culture of the service. These concerns had been investigated by the local authority and the provider, and no evidence was found to substantiate these claims. Staff told us they were able to challenge poor practice and the registered manager was open to feedback.

The registered manager toured the home regularly, was knowledgeable about people’s support needs and observations showed they had positive relationships with staff. One staff member said, “We are like a family. [Registered manager] will bring concerns to us and can be straight with he r views. [However,] they will help anyone; they will do anything they can to help staff.” Staff were able to tell how they would raise concerns and to whom they would raise them. We noted throughout the home there were contact details advertised on how to raise concerns with the local authority and CQC.

Lessons were not always learnt to continually identify and embed good practice. Some concerns noted at our last inspection were still present at this assessment.

We could not see evidence that all the concerns around safety were appropriately investigated. One person who had a deprivation of liberty safeguard (DoLS) in place to keep them safe, had managed to leave the premises unsupervised on several occasions. However, these incidents had not been investigated.

The registered manager shared raised concerns with staff in their morning meetings to raise awareness and gather feedback to drive improvements. Staff knew where and how to record incidents and felt confident the registered manager would act on raised concerns.

When 1 person had raised a concern with the operations manager we saw they had received a timely response scheduling when action would be taken.

The provider did not always act on the best information about risk, performance and outcomes.

Medicines audits had not identified concerns identified with the safe storage of medicines. Audits did not always identify when care plans lacked information to guide staff how people could be supported to meet their physical and emotional needs.

Staff did not consistently document they had completed scheduled tasks to protect multiple people’s skin integrity. There was no evidence management were aware of this lack of compliance or had taken action to drive improvement. This meant people could be at risk of avoidable harm.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Records reviewed showed the management team and staff worked with relevant professionals and agencies. For example, advocates, social workers, district nurses and general practitioners. Staff communicated and recorded information provided from health professionals when they visited people.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice to drive improvement.

We noted there were some repeat concerns found at this assessment that were noted during our last regulatory visit. However, the provider was responsive to the feedback shared at this assessment. They acted and implemented an action plan to address current concerns.

The registered manager told us they attended organisational meetings with other registered managers to share good practice. The operations manager told us they were in the process of introducing assistive technology that was designed for falls detection and falls prevention. They also stated that the concerns we noted at this inspection had been shared with the other homes, so improvements could take place across the organisation.