We carried out a review of the data available to us about Victoria Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Victoria Lodge, you can give feedback on this service.
There was a registered manager 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.
People were supported to maintain good health and involved in decisions about their health. They were provided with personalised care and support. Staff had the knowledge and skills to carry out their roles and their training was updated annually. People were very positive about the care they received.
Risks to people and staff safety were identified, assessed and appropriate action was taken. Staff had completed safeguarding adults training and knew how to keep people safe and report concerns. Staff had a good understanding of systems in place to manage medicines. People's medicines were safely managed. There were thorough recruitment checks completed to help ensure suitable staff were employed to care and support people. There was sufficient staff available to ensure people's wellbeing, safety and security was protected.
The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and report on what we find. People were supported by staff who had the skills and training to meet their needs. The manager and staff understood their responsibilities in relation to the MCA and DoLS. People were involved in making every day decisions and choices about how they wanted to live their lives and were supported by staff in the least restrictive way possible. People’s right to make their own decisions was respected.
Quality assurance procedures were used to monitor and improve the service for people and included them in developing their care and support. Feedback from people and their relatives or supporters was used to improve the service when their views were sought annually. Monitoring and auditing of systems had ensured that an action plan was created and those actions evaluated monthly.
People's independence was promoted and support workers encouraged them to do as much for themselves as possible. Staff treated people with dignity and respect and were sensitive to their needs regarding equality, diversity and their human rights. People were encouraged and enabled to be involved as much as they were able in making decisions about how to meet their needs.
The Equality Act covers the same groups that were protected by existing equality legislation – age, disability, gender reassignment, race, religion or belief, sex, sexual orientation, marriage and civil partnership and pregnancy and maternity. These are now called `protected characteristics. We reviewed one person's care plan which showed their individual religious beliefs and preferences had been considered.
There were regular opportunities for people and staff to feedback any concerns at peoples one to one meetings; house meetings, staff meetings and supervision meetings. Records showed these were open discussions. Feedback was consistently positive, with many complimentary comments about the support provided, the staff and the overall service.
We found that although people’s support plans and risk assessments were updated there was no evidence to support this and it was difficult to demonstrate review, however the service was responsive and involved people in developing their support plans which were detailed and personalised to ensure their individual preferences were known. The registered manager acknowledged this and was proactive in developing an evaluation sheet which they have put in place for each person.
People were supported to take part in activities that they enjoyed. Arrangements were in place to obtain the views of people and their relatives and a complaints procedure was available for people and their relatives to use if they had the need.
Staff told us they enjoyed working for the organisation and spoke very positively about the culture and management of the service. They also told us that they were encouraged to openly discuss any issues.
The registered manager had made links with the local college to provide apprenticeships to students to learn about mental health. The registered manager had also forged positive relationships with professionals involved in peoples care and support. Feedback from professionals was very positive.
The registered manager placed great importance on ensuring everybody was treated as an individual. They also ensured the staff team felt valued. The management team ensured that significant events were reported appropriately to the local authority and the CQC when required.