Victoria House

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

We assessed 4 quality statements in the well led key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. The rating for this key question has changed to requires improvement. We found a breach of regulation in relation to the governance of the service. We found that the service was not always well led. Inconsistencies in the management of the service had led to shortfalls in the oversight of the service and systems put in place to monitor the safety and effectiveness of the care had been ineffective. Audits that were in place did not always have an action plan to address identified issues. In some cases where an action plan was in place, action to address these areas of concern was slow. Risks had not always been assessed and records were not always accurate and up to date. Staff did not always feel supported in their roles; however, they were positive that improvements would be seen now a new manager was in post.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The current culture of the service required improvement as there was low staff morale. The inconsistent management and communication meant some staff felt there was a divide with management. However, staff were hopeful when the new management started things would improve.

The culture of the service needs improvements as the current staffing levels and inconsistent staffing meant people received task focused care which did not promote a positive culture.

Staff told us there was not always effective communication and engagement with management. Staff told us they did not always feel supported by management. The inconsistent leadership had led to instability at the service. Staff gave examples of how managers and put measures in place at the service and then other managers took these out causing confusion for staff. The quality assurance manager was aware the impact of unsettled management at the service had and they told us a new manager had been recruited which they were hoping would give the service stability.

There was a lack of consistent management and oversight of the service. There was no registered manager in post at the time of inspection and there had been multiple changes in management which had led to instability at the service. A new manager was due to start at the service.

Staff told us there was poor communication with the management team. We received mixed feedback if staff felt confident to approach management. Some staff did not always feel listened to and felt when concerns were raised action was not always taken.

The provider had systems and policies in place for staff to speak up. Measures were in place to protect people, for instance when people had raised complaints, staff's identities were protected as not all information was available to the management team on the log.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The quality lead was open in that they recognised the service needed to make improvements and that the provider was committed to doing so. They had developed action plans and identified areas for improvement, but action taken had not been sufficiently prompt to drive forward improvement.

The provider had failed to ensure compliance with regulations. The providers systems had not always identified or addressed concerns found at this inspection. This included concerns with risk management, record keeping, person centred care, staffing and Mental capacity assessments. Some areas of concern had been identified and action plans were in place, but they did not always promptly drive forward improvements. For example, an action regarding care plans and risk assessments was scored as high priority, however this has been ongoing for five months. Audits that had taken place were inconsistent in quality, some audits no action plan had been identified and the same areas were found on the next audit showing they had not been addressed. Multiple systems and processes in place made it difficult to navigate and ensure effective oversight of the service. For example, health and safety was recorded on a handwritten schedule, in a team folder and records in a notebook. The provider failed to keep accurate, up to date and contemporaneous records. This included people’s health care, care plans and risk assessments.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.