You are here

Victoria House Requires improvement Also known as Victoria House North East Limited

We are carrying out a review of quality at Victoria House. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 24 August 2018

This inspection took place on 10, 16 and 23 July 2018 and was announced. The provider was given 24 hours’ notice because the location was a care home for people with a learning difficulty, who needed to be advised and prepared for the inspection.

Victoria House 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 the care provided, and both were looked at during this inspection. The home is registered to provide support for up to nine people over two floors. It is a single home converted from three terraced houses. Residential care is provided for people with a learning disability, physical disability or those with an autistic type condition. Nursing care is not provided at the home. On all three days of the inspection there were nine people using the service.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. Registering the Right Support CQC policy

The home had a registered manager who had been registered since May 2017. 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.

Staff were aware of safeguarding issues and were confident about reporting any concerns around potential abuse. The home was working actively with services on issues external to the home. Monitoring was in place with regard to people’s financial affairs.

Checks were carried out on the equipment and safety of the home. The majority of checks carried out on systems and equipment were satisfactory. However, on the first day of the inspection we found upstairs rooms did not have window restrictors fitted. By the second day of the inspection this had been rectified. A risk assessment with regard to legionella was planned to be completed by the end of the month. Fire drills were undertaken at the home, although we noted none had taken place during the night shift. By the second day of the inspection the deputy manager had undertaken fire drills later in the evening and had also worked with the local Fire Service on a new fire plan for night staff. Personal emergency evacuation plans were not always detailed but contained information specific to the individual’s support needs.

People’s care plans contained risk assessments linked to their individual care plans. However, it was not clear how the levels of risk had been arrived at. We also found some areas of risk were not comprehensively covered or the level of risk did not reflect that detailed in local authority review documents. The home was maintained in a clean and tidy manner.

People and staff told us they felt there were enough staff on duty. Staff told us they were able to accompany people to access the community and support them with their personal care needs. Proper recruitment procedures and checks were in place to ensure staff employed by the service had the correct skills and experience.

Medicines at the home were managed appropriately. Medicines were safely stored and regular checks were made on stock levels and administration. Staff had received training with regard the safe handling of medicines.

Staff had an understanding of issues related to equality and diversity and what it meant for people using the service. They told us they had access to a range of training and updating and records confirmed this. They confirmed they had access to regular supervision and an annual appraisal and records supported this.


Inspection areas


Requires improvement

Updated 24 August 2018

Not all aspects of the service were safe.

Risk assessments were often limited in detail and did not always identify how risks would be minimised. Risk assessments did not always reflect information contained in local authority assessments. Personal emergency evacuation plans were not individual. Some issues with the safety of the environment were noted but addressed during the inspection process. Safety certificates for gas and electricity system were in place.

Staff had undertaken training on safeguarding issues and recognising potential abuse. Proper recruitment processes were in place to ensure appropriately experienced staff worked in the service. Staffing levels were maintained to ensure individualised care.

Medicines were managed safely and effectively. The home was maintained in a clean and tidy manner.



Updated 24 August 2018

The service was effective.

The service supported people with regard to equality and diversity. Records confirmed training was up to date and staff told us they received regular supervision and appraisals.

Appropriate processes had been followed in relation to Deprivation of Liberty Safeguards applications. Where appropriate people had been asked to give permission and consent.

People were supported to maintain adequate levels of diet and fluids. Regular access to health care services, to maintain wellbeing, was supported. Some areas of the home had been refurbished and updated.



Updated 24 August 2018

The service was caring.

People and visiting professionals praised the care and described it as individual and personal. We witnessed very good relationships between people and saw staff that were supportive and compassionate.

People had signed their care plans to say they were happy with the content. Involvement in monthly reviews of care was not always clear, but there was a monthly meeting for people to be able to express their views. Responses to an annual questionnaire about the service were highly positive.

People’s dignity was supported and their right to privacy respected. Information was provided in formats that supported people’s individual needs.


Requires improvement

Updated 24 August 2018

Not all aspects of the service were responsive.

Details contained within care plans were not always sufficient or did not reflect matters identified in assessments of care. Monthly reviews of care were variable and did not always consider how people had been during the period. Reviews often simply repeated care plan information.

There were a large range of activities available for people, taking place both in the home and in the local community. People talked enthusiastically about going on holiday and told us stories from their trips away.

There had been no recent complaints and people told us they were happy with the service. End of life wishes were recorded and supported.


Requires improvement

Updated 24 August 2018

Not all aspects of the service were well led.

A range of checks and audits were undertaken and actions identified and followed up. However, these had failed to identify the issues found at this inspection, including issues with regard to window restrictors, fire drills, risk assessments and monthly reviews of care. Other care records were well maintained and contained good detail.

Managers had a clear vision that they wanted the service to be personal and have a ‘family’ feel to it.

Staff talked positively about the management of the service and said they were well supported in all aspects of their work. Staff said they were happy working at the service and there was a good staff team. Regular staff meetings took place and staff told us they could actively participate in these.