Archived: Victoria Mews

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

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.

The provider demonstrated a positive culture of listening, kindness and compassion. The registered manager worked hard to ensure people received care and support in a relaxed environment. People, their relatives and staff consistently told us how the registered manager demonstrated kindness and support. One relative told us, “We are very happy and relaxed when we come here.”

There was a stable staff team which included diversity in the workforce. The management team were present on the floor. 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.

People and relatives told us the registered manager was approachable, proactive and engaged with people. A relative told us, “[The registered manager] is more than excellent, they are amazing.” Staff told us the registered manager had good oversight of the service, some comments included, “Management are brilliant”, “I feel supported by the manager, when I have had problems, they have supported me well and been very understanding.”

The registered manager had a strong focus on residents, they said, “We listen to residents, all of them have voices so make sure they are heard.” They also told us they felt supported by the provider and their staff team.

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

People told us they could raise concerns to management, and these concerns were dealt with. Staff told us they knew how to raise concerns: the provider had various channels to enable staff to do this. Staff were confident in the management team to address any concerns. A staff member told us, “We have regular team meetings where we are able to feedback as well as positive supervisions.” The registered manager told us they promoted an open culture where staff felt comfortable to raise any concerns. The provider had policies and procedures in place to support staff in speaking up and raising concerns.

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.

The provider had a diverse workforce and treated staff equally and fairly. Staff we spoke with told us the provider supported flexible working and time off when needed. The registered manager gave examples of adjustments they had made for staff with specific needs.

The provider operated a ‘Kindness in Care initiative’ which rewarded staff who had received positive feedback from people and relatives. This demonstrated acknowledgement, commitment and dedication of staff to the people they supported.

Staff told us they worked well as a team and enjoyed working at the service with people. One staff member said, “I love being with the residents. I go home and smile that I have made a difference.”

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.

The provider had a diverse workforce and treated staff equally and fairly. Staff we spoke with told us the provider supported flexible working and time off when needed. The registered manager gave examples of adjustments they had made for staff with specific needs.

The provider operated a ‘Kindness in Care initiative’ which rewarded staff who had received positive feedback from people and relatives. This demonstrated acknowledgement, commitment and dedication of staff to the people they supported.

Staff told us they worked well as a team and enjoyed working at the service with people. One staff member said, “I love being with the residents. I go home and smile that I have made a difference.”

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.

The provider had maintained oversight of the service in most areas through a structured approach. Regular audits and risk assessments were in place to monitor quality assurance and identify areas for improvement. For example, staff supervision, people’s dining experience and infection prevention control (IPC). Action plans were developed and regularly reviewed against the progress made

Accidents, incidents and safeguarding concerns had been recorded and reported however some medicine errors had not been reported to Care Quality Commission (CQC). We highlighted this to the manager who assured us they would include in the process. The provider’s systems produced regular reports on a range of compliance including staff training. The registered manager used this information to drive improvement.

The senior team monitored care delivery through audits and feedback which helped to address any concerns promptly and ensured people received good quality, person centred care while staying engaged with their community.

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.

The provider had maintained oversight of the service in most areas through a structured approach. Regular audits and risk assessments were in place to monitor quality assurance and identify areas for improvement. For example, staff supervision, people’s dining experience and infection prevention control (IPC). Action plans were developed and regularly reviewed against the progress made

Accidents, incidents and safeguarding concerns had been recorded and reported however some medicine errors had not been reported to Care Quality Commission (CQC). We highlighted this to the manager who assured us they would include in the process. The provider’s systems produced regular reports on a range of compliance including staff training. The registered manager used this information to drive improvement.

The senior team monitored care delivery through audits and feedback which helped to address any concerns promptly and ensured people received good quality, person centred care while staying engaged with their community.

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.

Management and staff collaborated with people and relatives and had regular meetings which gave them an opportunity to feedback to management. The home had a pub which hosted a range of events for people and relatives. Staff told us relatives were invited to evening meals where staff have set up the pub as a restaurant and dressed up as waitresses. The home had links with the local church and local schools. They had recently collaborated with a local organisation to provide support to local carers.

People were supported to attend appointments when needed and professionals visited the home regularly to meet people’s needs. Health and social care professionals reported the staff engaged well and sought support appropriately which contributed to improving people’s health and wellbeing. The registered manager worked closely with commissioners and were keen to develop further links to further improve people’s outcomes.

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.

Management and staff collaborated with people and relatives and had regular meetings which gave them an opportunity to feedback to management. The home had a pub which hosted a range of events for people and relatives. Staff told us relatives were invited to evening meals where staff have set up the pub as a restaurant and dressed up as waitresses. The home had links with the local church and local schools. They had recently collaborated with a local organisation to provide support to local carers.

People were supported to attend appointments when needed and professionals visited the home regularly to meet people’s needs. Health and social care professionals reported the staff engaged well and sought support appropriately which contributed to improving people’s health and wellbeing. The registered manager worked closely with commissioners and were keen to develop further links to further improve people’s outcomes.

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.

Management and staff collaborated with people and relatives and had regular meetings which gave them an opportunity to feedback to management. The home had a pub which hosted a range of events for people and relatives. Staff told us relatives were invited to evening meals where staff have set up the pub as a restaurant and dressed up as waitresses. The home had links with the local church and local schools. They had recently collaborated with a local organisation to provide support to local carers.

People were supported to attend appointments when needed and professionals visited the home regularly to meet people’s needs. Health and social care professionals reported the staff engaged well and sought support appropriately which contributed to improving people’s health and wellbeing. The registered manager worked closely with commissioners and were keen to develop further links to further improve people’s outcomes.

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.

Management and staff collaborated with people and relatives and had regular meetings which gave them an opportunity to feedback to management. The home had a pub which hosted a range of events for people and relatives. Staff told us relatives were invited to evening meals where staff have set up the pub as a restaurant and dressed up as waitresses. The home had links with the local church and local schools. They had recently collaborated with a local organisation to provide support to local carers.

People were supported to attend appointments when needed and professionals visited the home regularly to meet people’s needs. Health and social care professionals reported the staff engaged well and sought support appropriately which contributed to improving people’s health and wellbeing. The registered manager worked closely with commissioners and were keen to develop further links to further improve people’s outcomes.

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.

There was evidence of continued learning and improvement with action plans and reviews in place to demonstrate when issues had been identified and acted upon. The registered manager utilised well known studies to inform themselves on how to manage safety within the home, for example the Vivaldi study. This was a research project carried out during COVID-19 to understand how the virus affected people living and working in care homes. Staff told us a home learning meeting was held by the registered manager as soon as an issue was identified to inform staff on what they should be doing differently.

The registered manager demonstrated a willingness to learning and welcomed feedback to improve people’s outcomes and the quality of service provided.

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.

There was evidence of continued learning and improvement with action plans and reviews in place to demonstrate when issues had been identified and acted upon. The registered manager utilised well known studies to inform themselves on how to manage safety within the home, for example the Vivaldi study. This was a research project carried out during COVID-19 to understand how the virus affected people living and working in care homes. Staff told us a home learning meeting was held by the registered manager as soon as an issue was identified to inform staff on what they should be doing differently.

The registered manager demonstrated a willingness to learning and welcomed feedback to improve people’s outcomes and the quality of service provided.