Victoria Grand

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

There were inconsistent governance and management systems in place. Records were not always accurate or complete. This was a breach of the legal regulation in relation to governance. There was an inclusive and positive culture of continuous learning and improvement. This was based on meeting the needs of people who use services. Leaders proactively supported staff and collaborated with partners to improve the service and improve the quality of care being delivered to ensure it was safe and person-centred.

This service scored 68 (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 and manager were clear they wanted to improve the service and outcomes for people both in their experiences and the environment. A staff member told us that the provider had been working hard to address things. It was not clear if staff fully understood the provider's vision and culture as the staff member did not really see what changes care staff needed to make because of the issues identified at the previous inspection, as they believed care staff always worked well and provided good care.

The provider and the manager had kept up to date with local and national developments within health and social care and had attended forums, training and signed up to well known, reputable websites to find advice and guidance such as Skills for Care. Skills for Care supports adult social care employers to deliver what the people they support need and what commissioners and regulators expect. Daily shift handover meetings took place, however these required improvement. Staff handover meetings were very brief and not always documented.

The management team knew people well and were passionate about making changes to improve people’s lives. The manager was in the process of applying to become the registered manager. The manager worked on shift regularly as there was a staffing vacancy for a deputy manager. They explained this gave them a good understanding of any changes to people’s health and wellbeing and helped them to develop good working relationships with staff.

The provider had recruited a new manager. The manager had the skills, knowledge, experience and credibility to lead effectively. Support had been put in place to help staff in different positions. The management team led with integrity, openness and honesty to ensure care and support was delivered inline with people’s wishes, expectations to embody the culture and values of the workforce and organisation. People and relatives told us the management team had an open-door policy and made time to talk with them. A person shared how they had given the provider feedback about how staff had worked with them and changes were made as a result.

Staff confirmed they were invited to meetings and encouraged to contribute. Staff meeting minutes evidenced that these took place regularly. Staff were encouraged to voice their ideas for improvements and any concerns. Staff knew how to raise concerns with the provider or outside organisations if they needed to. A staff member said, “If they do not listen, we go up and up and eventually I would contact safeguarding myself or CQC if I thought it was not getting addressed.”

The provider had systems and processes in place to foster a positive culture where people felt that they could speak up and have their voices heard. Complaints processes were available in each person’s bedroom.

The provider told us they were well supported by a human resources company to provide employment advice. They utilised the expertise of the company when required.

The provider had processes in place to ensure there was an inclusive culture. The workforce was diverse and support was in place for staff to have training and communication in their preferred language (this had not been taken up). An employee assistance programme was in place for staff. Flexible working was in place with access to parental leave for staff with childcare responsibilities.

Staff told us they liked working in the service and the manager and provider were supportive and approachable. Staff we spoke with were confident that they could discuss any concerns with the management team and these would be acted on, they were aware of how to escalate concerns to senior management or outside of the organisation. However, the provider's process were not robust. Policies had not always been followed by staff and leaders.

The provider had an audit programme in place which was not fully robust. Regular audits were undertaken by the provider, the audit process had changed onto a new system. Records relating to some audits and checks could not be found. Audits and checks had not identified concerns and issues in relation to reporting food and fluid intake, missing risk assessments and building related checks. Actions taken as a result of the last inspection had not been fully completed. It was not clear that the management team had a thorough oversight of the outstanding actions from audits and checks, or a clear plan of when actions would be completed and who was accountable for achieving these. The provider had utilised a management consultant following the last inspection to help monitor, audit and implement changes required. Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. The management team had correctly submitted notifications to CQC. People's personal records were stored securely in the office. People's personal records were also stored on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so.

People and relatives told us about visits to the service from community nurses and other healthcare specialists. One person told us they had been out to their relative’s home for Mother’s Day. They also said, “I can go out to the shops if I want to.”

The management team explained how they received peer support from forums such as the local GP practice care home provider forum, Infection, prevention and control (IPC) social media groups and others. Skills for Care support had not been fully utilised to gain help and support, the Skills for Care had been used to gain training guidance and support.

A healthcare professional told us, ‘I think that Victoria Grand have been through a few managers over the last couple of years which is always disruptive to the team and can be for the residents with changes being made by a new manager. Now [name] is the manager I hope she will remain for some time as she genuinely seems to care and try her best for people. The team appears happy as far as I can tell.’

The provider had systems and processes in place to collaborate and work in partnership with health partners, social services and local authority contracting teams. This enabled them to share information and learning with partners and collaborate for improvement. The provider shared that the local authority had been to visit the service in late 2023. The service had also been visited by the fire service and was making some amendments to fully meet fire regulations.

The provider told us, that they and the service were looking at ways to innovate. They were exploring applying for a grant from the local authority to gain money for equipment which would support the service with falls management. New equipment had been installed to update the service, for example the call bell system had been upgraded and replaced in December 2023.

The provider had systems and processes in place to continuously learn, innovate and improve the service. Surveys were due to be sent to gain feedback from people, relatives, staff and professionals. People had completed surveys with staff to gain feedback about food. Meetings held with people also captured feedback and suggestions. The service has received one complaint since the last inspection which was because the GP surgery could not got through on the phone. The service had received a compliment from a healthcare professional. It detailed the support a person received from the manager during a speech and language assessment. It read, ‘This member of staff demonstrated incredible skill in upholding personhood through her interactions with [person]. She displayed consistent positive enhancers to uphold [person’s] needs across all domains of comfort, identity, attachment, occupation and inclusion. [Person] was empowered to eat and drink independently with appropriate prompts and pacing, and she fully collaborated with [person] on consent, acting in such a way to maintain respect and dignity at all times.’