Victoria Grand

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 good. At this assessment the rating has changed to 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.

Some improvements have been made since the last inspection, but there was a continuing breach of the legal regulation relating to good governance.

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. The workforce comprised people from a variety of ethnic backgrounds and cultures. A staff member said, “We have got people working from different backgrounds and cultures. We work as a team and respect each other, everyone is unique.” The registered manager shared their thoughts about the home and told us, “I would like everyone to be happy and we try and make sure they have a good quality of life, their needs are met, and we provide a homely atmosphere. My staff want to come to work, we provide a good work/life balance, making sure staff are supported. If they are happy and smiling at work, this transfers to the residents.” The provider’s Statement of Purpose stated, ‘Putting the people who use our service at the heart of all we do, ensuring they maintain their independence and influence the way the service operates.’

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.

Since our last assessment, the manager had registered with the Commission, and this had provided stability and continuity for people and for staff. The registered manager explained, “There had been several managers in the past, but with continuity of management now, staff feel like they are being listened to, and we have meetings to discuss things.” Staff felt supported by the management team. One staff member said, “They are good the management. I don’t know if they do a good job or not, I can’t judge them, but I do like them.”

People did not always feel they could speak up and that their voice would be heard.

Staff told us they did feel able to speak up and raise concerns, but that actions would not necessarily be taken. Staff had spoken to the management about staffing levels and asked if the number of care staff could be increased, especially during the morning shift from 08.00 until 14.00. At a staff meeting, the response to the request for additional staff had been denied since the dependency tool the provider relied on to assess staffing levels had indicated the staffing levels for the number of people was adequate. On site, we saw care staff were busy, and task-focused, and people were left on their own for periods of time, either in their bedrooms or in the lounge. Staff had also raised the issues of poor quality bedlinen. The provider told us this was being looked into, that new linen had been purchased, but had not yet been put into use.

The provider had a whistleblowing policy and freedom to speak up policy.

The registered manager understood their responsibilities under Duty of Candour and said, “We are open and transparent. If we have an incident, we notify relevant people, letting people know what has happened, next of kin, notifications to safeguarding and CQC or the police if relevant. Lessons are learned which we share with the staff team.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff felt valued and supported by the provider and registered manager. One staff member said, “There’s no discrimination here.” Another told us, “Everyone is supported. We have staff who are vegetarian because of their religion, and they are provided with a meal on a long shift. I don’t work on a Sunday, because I go to church.”

Staff completed a survey and gave their feedback about the home. Results were positive with staff rating all aspects of working at the home in the 90 per cent range.

At the last assessment, the provider’s audit systems were not sufficiently robust to identify areas for improvement. Whilst some improvements had been implemented, issues found at this inspection had not been identified through the provider’s auditing processes. Information about people’s care and support needs was not always accurate or contemporaneous. For example, daily notes for 1 person on a particular day stated they received personal care at 11.10, were offered a cup of tea at 11.13, a glass of water at the same time, and breakfast at 11.13. We were in the room during this time period, and none of the recorded events happened. The person had no hot drink or glass of water during this time. It was also recorded the person had breakfast at 07.21, 11.13 and 13.27, 3 times on 1 day. Then it was recorded that at 13.26, the person had lunch and pudding. We saw the person was eating their lunch at 13.10 and was given a cup of tea with their meal. We reviewed a range of audits including emergency lighting, fire alarms, health and safety, surveys from people and their relatives, and the business continuity plan. These were effective in identifying areas for improvement. However, a mealtime focus audit completed in January 2025 identified menus were not on display, meals should be plated up and shown to people to enable them to choose what they wanted to eat, and desserts were to be served separately. We found the menus were not on display, people were asked for their mealtime choices the day before, and desserts were served to people in their rooms at the same time as their first course. An emergency contingency plan provided guidance for staff. Statutory notifications were completed and sent to the Commission in line with regulatory requirements.

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.

The home worked with a range of health and social care professionals. The registered manager provided us with a list of people to contact to ask for their feedback. We contacted all these people, but only one response was received. However, feedback from a social work team on the provider’s file described the registered manager as, “Very on the ball with regards to [person] care and communication with the social work team.”

The registered manager said they had received support when discussing new admissions to the home, to discuss people’s needs and whether these could be met. Unfortunately, the local authority had not always been prompt in meeting their contractual obligations which had caused some difficulty for the provider. The home liaised with Skills for Care to provide some training, and staff attended a local managers’ forum.

The provider focuses on continuous learning, innovation and improvement across the organisation and local system.

Following the last inspection/assessment, the provider sent us an action plan to address the issues found at that time. Risk assessments had been reviewed and updated by the manager and included more detail where required. For example, within 1 person’s care plan, their epilepsy risk assessment lacked detail and guidance for staff; this risk assessment had been re-written. The provider and registered manager had completed risk assessment training and in buildings risk assessment. All risk assessments had been checked by an external consultant.