Victoria Grand

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Although some improvements have been made since the last inspection, there is a continuing breach of the legal regulation relating to safe care and treatment; there is a new breach of legal regulation relating to staffing. People were exposed to the risk of harm due to staffing levels and the risk of infection in the way the laundry was managed.

This service scored 56 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Residents’ meetings were held monthly and enabled people to raise any concerns or complaints they had. For example, at a meeting held in February 2025, activities were discussed; people were asked for ideas about what they would like to do.

Accidents and incidents were logged and were shared with staff through a message book and staff meetings. Where needed, advice was sought from health or social care professionals. Following a series of medication errors, the provider had sought additional medicines training for senior staff to mitigate the risk of similar events from reoccurring.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The home liaised with a range of health and social care professionals. District nurses supported people with specific health conditions; a community matron provided advice and guidance through regular contact with staff.

People were supported to access specialist services when required. For example, a person needed orthotics and was referred to a podiatrist for treatment on their feet. People at high risk of falls were referred to the falls team for advice on mitigating their risk of falls. Specialist equipment, such as pressure relieving mattresses, supported people at risk of skin damage.

The provider did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. People were not always protected from the risk of harm. The Commission had received notifications relating to the allegation of sexual abuse and, whilst appropriate action was taken at the time of each incident, similar allegations kept reoccurring. (The person has since been moved to another home.) One person told us they often had people coming into their room, and this had frightened them, especially at night. This person told us they had seen another person come into their room and rummage through their personal belongings. The registered manager and provider were aware of the concerns. Many of the incidents involved people living with dementia who required more intense support by staff. A healthcare professional told us they had offered training to staff on supporting people living with dementia, but the offer had not yet been accepted. People felt safe with regard to their mobility needs. Sensor mats were used to alert staff if people required assistance with moving around their bedrooms. Staff completed safeguarding training. One staff member explained the different types of abuse they might encounter. For example, if they found a person with unexplained bruising, they would take a picture, report it to a senior member of staff and they would make a safeguarding referral. Notifications of abuse or alleged abuse were received by the Commission and safeguarding referrals were completed as needed.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were supported with their independence. One person told us they were able to transfer independently from their chair to a commode, as long as this was positioned next to them. The person said although they found it difficult to transfer themselves, they valued their independence.

Processes were effective in identifying, assessing and managing risks. Information within risk assessments provided good guidance for staff. Incidents and accidents were logged, and included the outcomes and derived learning. Advice was sought from healthcare professionals, including supporting people with their mental health needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

At the last inspection/assessment, concerns were raised with regard to a leaking roof in the conservatory, building works being undertaken in the home, and thermostats regulating the heating. All these issues have now been addressed. The conservatory roof was to be repaired pending the necessary planning permission. Refurbishment and redecoration on the top floor were being undertaken safely. The floor was closed to people and only staff who needed to access this floor were able to. Problems with the heating had been attended to, so all parts of the home felt warm and comfortable.

Signs around the home assisted people with orientation. For example, a sign with 1 person’s name on it and an arrow, helped the person to find their bedroom. Baskets containing clean laundry had been left on a counter outside the lounge. These were unsightly and had been left there for staff convenience when folding the laundry. By the second day of our inspection, these baskets had been removed to the laundry room.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

People told us they did not feel there were sufficient staff on duty. One person told us they spent a lot of time in their bedroom and did not really see the staff. They said, “Staff come with my food, that’s about it. I don’t really see anyone. I’m bored.”

Although the provider used a dependency tool based on the hours needed to provide personal care to people, the tool had not accounted for the additional responsibilities undertaken by care staff. Care staff also made people their breakfast, cleared away, and supplied drinks throughout the day. One staff member said, “You can imagine in the morning, staff take time doing medicines and can’t be distracted. Then there are 2 carers. If a person is not feeling well, we spend time with them. The manager does help but can’t be here all the time. We check and sort the laundry, get breakfast and top drinks up. We make sure people have drinks and beakers in their bedrooms and make sure call bells are within reach. We do have an activities lady who brings drinks. We try and help each other.”

We spent time in the communal lounge in the morning. Although staff popped in and checked on people, providing drinks as requested, there were periods when people were left on their own.

We discussed staffing levels with the registered manager and provider. They explained the number of care staff was calculated based on the dependency tool they used. In addition, the staff member providing activities was on duty during the day. However, on the day of our visit, the activities person had gone out with a person to a health appointment, so was not available during the morning. Since the inspection, we have been informed that some people with high support needs have moved out of the home.

New staff were recruited safely.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Although the home was generally clean, we found the management of dirty laundry was unsafe. When laundry becomes soiled, this poses a greater infection risk, and dirty linen will be placed in a red bag which is then washed at a very high temperature. We found red laundry bags in an upstairs bathroom during the morning and these were only removed a couple of hours later. We looked in the laundry room which was situated in an outbuilding. We saw dirty laundry was placed next to clean laundry. This was in contravention of the provider’s laundry policy which stated, ‘Laundering of linen in order to minimise the risk of infection’ and there should be a ‘dirty to clean workflow system.’ We discussed these issues with the provider and registered manager who reassured us they would take steps to ensure laundry was managed differently, with coloured containers denoting whether laundry was clean or dirty.

Staff completed training on infection prevention and control and personal protective equipment was used as needed. Infection control audits had been completed. During a recent diarrhoea and vomiting outbreak, the home was closed to visitors, a notice was placed on the front door, and extra cleaning was undertaken. The registered manager said, “We asked people who presented with symptoms to stay in their rooms, which most people did. We notified families and CQC.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We observed people receiving their lunchtime medicines. This was done safely and sensitively. The staff member sanitised their hands between giving each person their medicine. People were asked if they needed pain relief. Staff completed medicines training and their competency to do so was overseen by the provider, who had received appropriate training.

Medicines were ordered over a 28-day cycle, and any unwanted or unused medicines were disposed of through the pharmacy. Medicines that required a more secure method of storage were managed well. For people who required blood thinners such as Warfarin, they had regular blood tests; variable dosages of these medicines were recorded and administered safely. Medication administration records were completed appropriately. Medicines audits identified any actions that were needed. For example, in December, it was noted that some out of date medicines had not been returned. Any issues identified were addressed as needed.