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Inspection Summary

Overall summary & rating


Updated 9 February 2019

The inspection took place on 18 and 23 May 2018 and was unannounced.

Victoria Lodge is a residential care home registered to provide accommodation and care for up to 23 people, the majority of whom have a diagnosis of dementia and/or other care needs. At the time of our inspection, 21 people were living at the home. Communal areas include a sitting room, dining room/conservatory and access to a rear garden. Accommodation is over three floors and is serviced by a lift. Victoria Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and care provided and both were looked at during this inspection.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Following the last inspection, the service was rated as 'Good' overall, with 'Requires Improvement' under 'Effective'. At the last inspection in May 2016, we asked the provider to take action to make improvements in relation to staff training, supervision and appraisal. Improvements had been made in these three areas and the service remains rated 'good' overall.

Notifications that the provider was required to send to us by law had not been done in relation to Deprivation of Liberty Safeguards authorisations. Records such as Medication Administration Records (MAR) had not always been completed accurately. Information relating to prescribed medicines on MARs had been hand-written by a member of staff, but had not been checked by another member of staff in line with the service's quality assurance process or National Institute for Clinical Excellence guidelines. The services quality assurance processes had not picked these omissions up and therefore is an area that requires improvement.

Some information was provided in an accessible format and the registered manager informed us this was work in progress. Activities were organised for people.

Staffing levels were consistent, Staff commented on how busy it could be at certain times of the day.

Staff knew how to keep people safe and had completed training in safeguarding adults at risk. A range of risk assessments had been completed in relation to people and premises. New staff were recruited safely. The home was clean and tidy and staff had completed training in infection control.

Staff completed a range of mandatory training and were encouraged to study for vocational qualifications. Menus for people were planned in line with their dietary needs, likes and dislikes. Drinks were freely available. People received support from a variety of healthcare professionals. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

People were looked after by kind and caring staff who knew them well. As much as they were able, people were involved in day-to-day decisions and choices. Staff were reassuring and friendly with people and treated them with dignity and respect.

Care plans were detailed and written in a person-centred way. Activities were organised for people and there were plans to employ an activities co-ordinator. Complaints were managed in line with the provider’s policy.

Staff were involved in the development of the service and their feedback obtained through staff meetings. Employee satisfaction surveys had been completed by staff to gain their views about working at the home. Compliments from relatives were received and recorded. Residents’ meetings took place and people were asked for their views and suggestions about the

Inspection areas



Updated 9 February 2019

The service was safe

Staffing levels were consistent.

Management of medicines was safe

Staff had completed training in safeguarding and understood how to keep people safe.

Recruitment systems were robust.

The home was clean and tidy.



Updated 9 February 2019

The service was effective.

Improvements had been made with regard to staff completing a range of training.

The premises was being made �dementia-friendly�.

People enjoyed the food on offer and had access to a range of healthcare professionals and services.

Staff had completed training in mental capacity and put what they had learned into practice. People�s consent was gained lawfully.



Updated 9 February 2019

The service was caring.

People were looked after by kind and caring staff who knew them well. They were treated with dignity and respect.

People were encouraged to make decisions relating to day-to-day choices and their care.



Updated 9 February 2019

The service was responsive.

People and/or their relatives were involved in reviewing the care plans.

Activities were organised and planned for people living in the service.

Information was provided for people in an accessible format.

Care plans provided information and guidance to staff about people�s care and support needs.

Complaints were recorded and outcomes documented.


Requires improvement

Updated 9 February 2019

Some aspects of the service were not well led.

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.

Quality assurance systems had not always been effective in identifying issues.

The provider was aware of their responsibilities in relation to Duty of Candour and a whistleblowing policy was in place.

Staff meetings were held and employee satisfaction surveys were completed.

Residents� meetings were held so people�s views could be obtained. A number of compliments had been received from relatives, thanking staff for the care their loved ones had received at the home.