Victoria Mews

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

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 remained good.

This meant people were safe and protected from avoidable harm.

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 promoted a positive learning culture that encouraged openness, honesty and continuous improvement.

Staff listened to concerns about safety and were confident reporting incidents and safeguarding issues. One person told us they felt “very safe,” explaining that staff gave them confidence and reassurance. Accidents and incidents were recorded and reviewed by senior staff, and learning from these was shared promptly with the team. Actions taken were clearly communicated, and regular meetings were used to embed changes in practice. These processes helped reduce the risk of incidents recurring and supported a consistent, safety‑focused approach. Effective oversight from the provider ensured the service remained transparent and maintained strong governance around learning and safety.

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.

Prior to admission, a thorough assessment of the person’s needs was completed. This involved the person, their relatives and other professionals involved in their care to ensure their needs could be met.

Staff and managers had a good understanding of people’s needs, which helped to establish and maintain safe systems of care. One healthcare professional told us, “Continuity of care is very good, the home is very responsive. For example, consistent staff teams and the sharing of information.”

People were supported to maintain their health and attend appointments. The service worked in partnership with the Integrated Care Lead. They visited the service regularly to check people’s health and wellbeing and supported staff to signpost to relevant services when needed. This helped to ensure referrals were made where concerns were identified to supporting early intervention and potentially reducing the risk of avoidable hospital admissions.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that people who did not have the capacity to agree to their care and treatment had the appropriate legal safeguards in place, including Deprivation of Liberty Safeguards (DoLS).

People told us they felt safe. One person said, “I’m safe… there are no dangerous characters here.” Staff had received safeguarding training., One staff member told us, “I have done training, I would report neglect or if people are not treated well. We are here to support and make sure the residents are safe”.

Systems were in place to ensure safeguarding concerns were reported to the local authority.

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.

Care plans were detailed and person centred which helped staff to understand how best to support people and respond to their individual needs. Diabetic plans were specific and robust and provided clear guidance to ensure safe and consistent management of people’s health. Staff told us, “We are always told when there are any changes.”

Risks were managed well with a balanced and proportionate approach and a strong focus on maintaining people’s independence. The registered manager told us, “Resident’s independence is paramount, we take a collective approach to ensure everything is done in the least restrictive way.” They shared examples of how they worked with different healthcare professionals, GP and Occupational Therapists (OT) to gain people’s independence. One professional told us, “I have such a good relationship with everyone and with residents.”

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

The service was clean, well maintained and free from unpleasant odours. Health and safety checks were completed regularly. Staff told us, “If I see something that is broken, I make sure to report it in the maintenance book which is in the front desk. It never takes long to get things fixed.” Corridors and bedrooms were painted in different colours to support people to orientate and help to identify their rooms more easily. People’s bedrooms were personalised and well maintained to support their needs safely.

Fire safety procedures were in place, with clear signage displayed throughout the service to help keep people safe. Personal emergency evacuation plans were accessible and kept up to date with photos to help staff and other professionals support people in an emergency.

Daily, monthly and yearly checks were in place to monitor and maintain premises and equipment, with all actions recorded on an accompanying action plan.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

All required employment checks had been carried out. This included right to work documentation, reference checks and Enhanced Disclosure and Barring Service (DBS) checks were carried out. DBS checks provide information about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

The provider had a robust induction and training process in place. Training completion was monitored via an online spreadsheet. One person told us, “All the carers look well trained and competent.” Staff told us they had positive supervisions and a growth conversation annually to discuss their development.

Overall, people, relatives and staff told us enough staff were available to meet people’s needs safely. We observed staff responding to people’s needs promptly with kindness, care and compassion.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff followed cleaning schedules using appropriate products to help manage infection risks and maintain cleanliness in the home. Systems were in place to audit all areas of the home as well as a process for the registered manager to check people’s personal care needs were being met.

However, during our observations at breakfast, we found a food item that had not been labelled in the dining room. One staff member was not wearing appropriate personal protective equipment whilst serving food. We mentioned this to the staff member and registered manager, and they responded and acted promptly to rectify the issues. Food stored in the kitchen was appropriately stored, labelled and prepared in accordance with required standards.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines administration was well managed. We observed staff supporting people with patience and encouragement. Stock levels were monitored to ensure the correct number of medicines was kept in stock. Medicines were stored appropriately in a locked facility.

Appropriate guidance was in place on the electronic administration system to support staff with when to administer as and when required (PRN) medicines.

The provider had a good oversight of compliance which included an annual audit from an outside agency. The registered manager liaised with the local pharmacy and GP to ensure people received their correct medication.