Updated 25 January 2024
We carried out this assessment between 12 March 2024 and 7 May 2024. We looked at how the Victoria Grand assessed and planned for people's care needs, and how they trained and supervised staff to support people according to their needs and preferences. We found two breaches of the legal regulations in relation to safe care and treatment and governance. We reviewed a range of records.These included staff training records, meeting records, policies and procedures and audits. The provider's processes and procedures had not always been effective which meant some people were at risk of harm. This evidenced that the safe domain was not consistently good. Although staff delivered good quality care which met people's needs and respected people's wishes and dignity, they had not always received all the training they needed. The provider had some staffing challenges which meant members of the management team had been deployed to carry out caring roles as well as cooking which meant that some areas of quality assurance, health and safety and reporting had been missed. The provider's audit programme was not fully robust. 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. This evidenced that the well led domain was not consistently good. We have asked the provider for an action plan in response to the concerns found at this assessment.