Victoria House Also known as Victoria House North East Limited

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 – 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 inspection we rated this key question requires improvement. At this inspection the rating has changed to 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 79 (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.People were at the heart of the service. Staff listened to people and respected their decisions. For example, about who they were willing to share information with and be involved in decisions about their care. The ethos of person-centred support and enablement was intrinsic within the service and the belief that people had a right to live a fulfilled life and be supported to achieve their potential. People were encouraged to be involved in the running and development of the service. For example, people who were interested, were supported to learn about interviewing new staff so they could be involved and be part of the interview process. This meant people had some ownership, involvement and influence in the selection of staff who were employed to provide care to them. New staff received support and training which helped them to demonstrate the provider’s values in their daily work with people. Staff were proud of their caring approach towards people and believed strongly in the values of the service. Their comments included, “I feel very valued. I wish I had been here years ago. It is a fabulous place. They care about me as well as the residents. I cannot fault them”, “It does not feel like work” and “People are part of the provider’s family, it is like an extended family.” A relative commented, “Nothing could be improved.”

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. The registered manager and provider had made several improvements to the running of the service. People, staff and professionals were complimentary about the registered manager. Their comments included, “I have always found the manager very responsive”, “I can go to the manager, she is very supportive” and “The manager runs a tight ship. I would recommend them, she cares about the residents.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.There was a clear whistle blowing policy. Staff could raise concerns, and written information was available on how to do this. Staff meetings took place, and staff had the opportunity to share comments and give feedback. A staff member commented, “Without a doubt we are listened to and can discuss any issues. I think they, [provider and registered manager] are on top of things.” People were informed of the complaints procedure when they started to use the service and at meetings.

The provider valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they were able to ask for reasonable adjustments to be made to their working patterns for specific needs, for example to incorporate family commitments.

Improvements had been made by the provider and registered manager to ensure governance was more effective and robust, including the monitoring of the quality of service provision. The service had clear responsibilities, roles, systems of accountability and better 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. Regular audits and checks were carried out in the main areas of the service, such as, around care records, health and safety and staff practice. Audits showed action was taken where areas of improvement were identified. The registered manager was aware of their responsibilities regarding the Duty of Candour. Since the last inspection an external company had been employed to update policies and procedures and to strengthen the governance system, including providing external oversight.

Staff at the service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. All professionals fed back the service worked in partnership with them. A professional commented, “Whenever making suggestions, staff have been attentive and shown to listen and follow advice.” The service and organisation also gave back to the community through various charity initiatives which benefited people who used the service and the local community. They organised several fund-raising events, suggested by people to raise money to support the NHS, and charities.

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. A staff member told us, “We have a monthly reading list of policies to read.” There was evidence of changes that had been made to the service to make improvements and to address checks and audits outcomes and in response to people and staff feedback. External quality assurance arrangements were in place to monitor the internal governance systems.