Archived: Victoria House 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 good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 and people felt there was a positive culture at the service. Communication channels between people, staff and management were open and effective. The registered manager was proud of how the staff team promoted the service’s values. When asked whether there was good staff morale, a staff member said, “Victoria House Care Home has a good working environment where staff work and help each other.”

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.

The registered manager had good oversight of the service. Staff said the management team were supportive. When asked whether the registered manager was fair and approachable, all the staff we spoke to answered positively. As staff member told us, “Management are approachable and visible. They provide guidance during difficult situations and encourage staff to reflect and learn rather than place blame.”

The registered manager was actively involved in the day to day running of the service and was knowledgeable about people’s needs and knew people well. They had the skills and experience required to lead the home.

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

Policies and procedures were in place to make it easy for staff to speak up. All the staff we spoke to were aware of the process to raise problems and how to contact the provider if they needed to. When asked what freedom to speak up meant to them a staff member told us, “Staff understand freedom to speak up as being able to raise concerns about care and safety without fear.”

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 told us they were a diverse team who worked together well. Staff spoke positively about their experience of working at the home and told us they had not experienced any harassment or bullying.

The registered manager ensured staff had undertaken training in relation to equality and diversity and staff’s knowledge and understanding of people’s individual diverse needs was apparent when they spoke about the people they supported.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were well established systems in place to maintain oversight of the service and drive any necessary improvements. Regular checks were carried out on the environment, equipment, incidents, accidents and medicines. The registered and deputy managers undertook a range of audits to monitor the quality of care provided and reviewed the experiences of people living at the service. Completed audits were then used to create action plans, which detailed where changes or improvements were needed to improve quality and safety.

The registered manager understood the legal requirements of their role and the importance of their role and responsibility. They ensured notifiable incidents were reported to CQC in a timely way.

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 registered and deputy manager and the staff team worked in partnership with local agencies to ensure people’s needs were met. Records showed they worked closely and effectively with professionals from health and social care services.

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 and research.

The registered manager and staff worked in partnership with other agencies involved in people’s care which helped ensure they received a consistent and effective service. Staff and people told us how the service was part of the community and people regularly used the minibus for activities such as going to local garden centres.

There was evidence of learning through observation and complaints, and the registered manager spoke positively about the opportunities through learning from incident and events. They took a proactive approach to the inspection and were receptive to feedback provided.

The registered manager promoted learning for the wider staff team which in turn improved the quality of life for people living at Victoria House. One member of staff had completed an enhanced dementia training course. As a result of this additional learning, adaptations had been made to the dining experience which had significantly improved people’s health and well-being. People were observed to sit and enjoy their meal and truly embrace the dining experience.