Victoria Grand

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

People were not always protected from avoidable harm because risk assessments were not always clear, comprehensive and up to date. They did not always contain enough information about people’s risks and mitigation strategies for staff to provide safe and effective care. Some areas of maintenance identified at the last inspection had not been addressed . This was a continued breach of the legal regulation in relation to safe care and treatment. Staff and leaders were able to identify situations that amounted to safeguarding and staff were confident to use the whistleblowing process if needed. Staff knew people well and were able to identify changes in behaviours and presentation that meant that people were feeling anxious, upset or concerned about something. Lessons were learned when things went wrong. Medicines were administered and recorded safely. Medicines policies had not always been followed by staff in relation to monitoring temperatures of medicines storage and self administration. Staff were recruited safely and were supported through training, there was a plan in place to make sure they had ongoing support in the form of supervision and appraisal meetings. There were enough staff to support people safely. Ongoing training made sure that staff had the skills needed to support people. However, staff had not undertaken all additional mandatory training required. We spoke with the provider about this and they confirmed they would book this training for staff. Accidents and incidents were reviewed and actioned by the management team, safety checks were undertaken by staff. The provider worked with people and partners including local authority care managers and health professionals to establish and maintain safe systems of care. The provider had systems and processes in place to detect and control potential risks in the care environment and processes in place to assess and manage the risk of infection.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A person told us that when there had been an incident that the provider reviewed what had happened and sought advice from others to prevent it from happening again such as making a referral to the district nursing service.

Staff told us that accidents, incidents and changes were recorded electronically and documented in handover documentation and meetings. The management team said they were open and transparent with family members and people. The manager said, “Any incidents or concerns would be shared at handover meetings and staff also read a folder of information for recent updates concerning people.”

The provider had a culture in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices. Accidents and incidents were reviewed and actioned by the management team, safety checks undertaken by staff including maintenance, were audited and checked by the management team. This enabled the management team to make continuous improvements. The management team were still in the process of embedding improvements.

People were supported to maintain their health, attend appointments both inside and outside of the service. Where routine health checks were undertaken people had support from people who they know well to understand what was happening. People were supported with transitions between different services. A person had moved to the service on a temporary basis and was working with their social worker and the management team for a more permanent solution. The person was happy at the service.

The manager explained that they worked with others to resolve problems and make improvements. The service had maintained regular contact with local authority social workers. As well as good ongoing work with nurse practitioners, community matrons and doctors.

A healthcare professional told us the management team sought advice frequently and picked up when people may need additional medicines or support. '[Name] Manager is very good at reaching out for assistance.'

The provider worked with people and partners including local authority care managers and health professionals to establish and maintain safe systems of care. Safety was managed, monitored and assured. When people were supported to go to hospital, either through routine and planned admission, emergency admission or consultation day visit, hospital passports were in place. A hospital passport helps hospital staff as it provides important information about people and their health when they go to hospital.

People were safe and were protected from harm. A person told us, “I feel safe.” A relative told us they were “Happy that she is safe and they are caring for her.” Staff were attentive to people’s needs and made sure they were safe as they carried out their daily routines. Relatives told us they were confident to raise any concerns and knew that they would be responded to.

Staff had received adult safeguarding training and had yearly refreshers. Staff understood their responsibilities to report a safeguarding concern. Staff were similarly aware of whistleblowing and were confident to speak up if needed.

We observed several interactions between staff and people during our visit. We saw safe practice whilst allowing people to maintain their routines and come and go around the service as they wanted.

Safeguarding and whistleblowing policies were in place and were accessible to staff. Staff knew how to whistle blow and prior to the assessment we had received a number of whistleblowing concerns. We looked at safeguarding case records for the service. This was not fully up to date. There was no monitoring sheet in place for 2024. However, the management team did detail that actions had been taken and appropriate referrals and contacts made appropriately. The management team told us they had positive working relationships with the local authority and other statutory partners and were confident to seek advice and report safeguarding issues in a timely way.

People and their loved ones gave us mixed views about how staff managed risks well. People told us about equipment they used to keep them safe. A person told us they had not felt safe when staff supported them to mobilise using a wheelchair without a seat belt. They added, “The home manager has made it clear to staff they are not to use the commode chair to move me from one place to another as it was not safe, there are no straps on it. But this did sometimes still happen”. A relative told us that staff picked up on changes to their loved one’s behaviours and presentation and knew them well. They said, “I know someone is checking on him regularly and they have support from the mental health team.”

Most staff knew people well and were confident they could identify any changes in people’s presentation that may be of concern. Some newer members of staff did not know people and risks associated with their care as well as others but told us they had access to all the information on the electronic care planning system.

We observed that some risks were not always well managed, such as a portable oil fired heater was against a sofa. This heater was moved to a safe place after we drew the manager's attention to this hazard. We observed safe interactions between staff and people. People moved around the service safely and were supported to spend time where they chose. We saw people being given the food and fluid consistency in accordance with their needs including diabetic diets. The food was well presented, and people seemed to be enjoying the experience. Staff checked on people eating in their rooms to make sure they were eating and were safe.

Risk assessments were not always clear, comprehensive and up to date. They did not always contain enough information about people’s risks and mitigation strategies for staff to provide safe and effective care. Epilepsy risks were not fully documented, understood or identified. Risks relating to inadequate food and hydration not being managed well, which put people at risk of harm. Actions had not been taken to ensure that people had always received adequate levels of fluid to keep them healthy. Building related risks were not always addressed in a timely manner. The service was undergoing significant building works, risk assessments and impact assessments had not been completed

Some people were impacted by maintenance and building works, as they were having to move rooms. A person was unsettled by this as they did not understand why they needed to move.

We spoke with the provider about the leaking conservatory is as this was identified at the last inspection. They told us there had been delays due to specific permissions which they needed for different roof types, structural engineers were involved. The provider told us the conservatory was still safe to use as electrical work had been undertaken to move electrics which were affected by the water. Staff told us the service was cold in places.

A redecoration programme was in place, contractors were working in empty rooms. They were working safely behind closed doors. The areas already completed appeared to be well maintained. There were some areas of the service where maintenance tasks had not always been completed in a timely manner. For example, we observed carpet in one area that had been stuck down with tape because it had been damaged, the tape in one area had become rucked up which could of caused a trip hazard. This was immediately fixed when we reported it to the management team. Some areas of the service were cold and portable oil filled radiators were in use. The management team explained that the heating was working but there was a problem with thermostats being sited in the wrong place. They were in the process of liaising with contractors to add more thermostats to the heating system. The conservatory, which was in use was in disrepair and was leaking, bowls were collecting rainwater. We spoke with the provider about this as this was identified at the last inspection. They told us there had been delays due to specific permissions which they needed for different roof types, structural engineers were involved. The provider told us the conservatory was still safe to use as electrical work had been undertaken to move electrics which were affected by the water. Rooms were clean and tidy and had been personalised in accordance with the person’s wishes.

The provider had systems and processes in place to detect and control potential risks in the care environment. This made sure that the equipment, facilities and technology supported the delivery of safe care. Essential servicing and maintenance of the gas, electric, lift, fire alarm system, emergency lights, moving and handling equipment had taken place. Some records in relation to checks, weekly fire tests and window restrictor checks were incomplete or missing. The provider told us they were working to improve these. Contractors were working in the service and the maintenance team were undertaking repairs. The fire alarm had been replaced as had the nurse call alarm system.

People and their loved ones told us that staff were kind. People commented, “They are all really nice staff, I really like it here”; “Staff answer call bells quite quickly” and “Staff do understand what you need and know you well.”

Staff told us about the training and support that provided them with the skills they needed to support people safely. A staff member told us, “We wait for them to tell us to do the training and we do it, online. Last week we had manual handling training by an outside trainer. That was nice as it gave us the opportunity to discuss with each other, ask questions as we went along and be part of a team, so we all learn the same thing.” Another staff member said, “I had 1 supervision with [previous manager] before she left, it covered if I had any issues, my observations and how to help me work better. I think it would be helpful if I was to have them on a regular basis.” They were knowledgeable about the people they were supporting and had a good understanding of the management of health conditions such as diabetes and epilepsy.

We observed there were enough staff on duty to support people, however, there were times when people were left unattended in communal areas. Duty rota’s were completed in advance and a few gaps were filled by staff completing extra hours and agency staff were used when needed.

Staff had been safely recruited. We examined 2 staff files and all of the required checks had been carried out and documents were all in date. In files we saw copies of references, interview notes, photographic identification and Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. The provider’s systems for monitoring the status of overseas workers were not fully robust. The provider acted on this and took advice from their human resources provider and from The Home Office. Staff had not had regular supervision meetings. The management team had recognised this and had planned in meetings with staff. The provider’s training matrix showed that staff had not all had mandatory training. Staff were required to attend additional safeguarding training and Oliver McGowan training. Staff responsible for carrying out risk assessments and had not completed risk assessment training. We discussed this with the management team as an area for improvement.

People did not share any negative experiences about the hygiene and cleanliness in the service. A person told us that the provider had been responsive to a request to have a fly zapper placed in their room, which they were happy about.

Staff told us they had sufficient equipment and PPE (Personal protective equipment) to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks.

We observed that the staff were using PPE effectively and safely. We were assured that the provider was promoting safety through the layout and hygiene practices of the premises. There were no restrictions to visitors. We observed visitors coming and going freely during the assessment.

The provider had systems and processes in place to assess and manage the risk of infection. They were able to detect and control the risk of it spreading and share any concerns with appropriate agencies promptly. The provider had a daily cleaning program in place. The service employed housekeeping staff to carry out daily cleaning, cleaning schedules were in place which included deep cleans for people’s rooms. Infection control audits were completed regularly and actions taken if any issues were found. The provider had plenty of PPE in place to keep people and staff safe. The kitchen areas were clean and well managed, shortly after the assessment site visit the service received an unannounced environmental health check of the kitchen which passed and the service was awarded a 5 star rating.

People received their medicines safely. A person said, “I do have my medication in the evening though (after supper otherwise I feel sick.)” We observed the staff were polite, gained consent, and recorded the administration of medicines on the medicines administration record (MAR).

People received their medicines from trained staff. The staff informed us they received training. The management team told us staff were competency assessed to handle medicines safely. People were supported by the local GP, nurse practitioner and community matron.

The provider had systems and processes in place to manage medicines. Some improvements were identified. Some people were prescribed medicines to be taken only when required known as (PRN) medicines. Guidance (PRN protocols) were in place to help staff give these medicines consistently. There was a medicine policy in place, however this was not always followed. For example, a person kept their PRN medicine with them. A self administration of medicines assessment had not been completed and was not in the person’s care plan. The staff had not always checked and recorded the temperature of the medicine storage room and medicines storage fridge daily. Records showed that temperatures had not been recorded for 10 days in March. This meant there was a risk medicines could be stored at temperatures outside of manufacturers guidance. Medicines care plans and risk assessments were detailed and person-centred. They provided good information to support staff to understand people's care needs and linked to care planning for specific conditions. The ordering process for prescribed medicine was effective, and we were able to reconcile medicines stock with prescribing. The management team carried out regular medicine audits.