The Old Vicarage

The Old Vicarage is a residential care home providing accommodation and personal care for up to 41 older people. At the time of our inspection there were 39 people using the service.

The Old Vicarage comprises the main home for up to 29 people, and a new building for 12 people. The new building provides spacious rooms, and there were small outside spaces attached to each room. The main home has a dining area which all people had access to and pleasant outdoor areas with seating.

People’s experience of using this service and what we found

Significant improvement was needed to ensure people always received good quality, compassionate, individualised and safe care as a minimum standard.

People were not supported safely. Risks to people were not always robustly assessed and mitigated. Staff did not always have the information they needed to provide safe care because risks associated with people's care had not always been fully assessed. This included for falls, diabetes, and choking. Medicines were not always safely managed. There were not sufficient numbers of suitably skilled staff to make sure that they could meet people's care and support needs. Staff were not always recruited safely.

Infection prevention and control was not well managed. We found the service to be unclean in multiple areas including people’s rooms, the main kitchen, and laundry. Staff were not disposing of PPE safely.

People were mostly supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Further work is needed to ensure mental capacity assessments and best interest decisions are in place for all aspects of people’s day to day care, but work had begun on this.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic. Staff received training in learning disabilities, however, the registered manager was unaware of the statutory guidance.

The service lacked effective leadership and risk management. The provider's systems for monitoring and improving the quality of the service had not been effective, because people were not always receiving a good quality of service and some risks had not been mitigated. This placed people at continued risk of harm.

The provider was responsive to the inspection findings, they told us they were willing to learn, improve and share the actions they would take to address the issues found at this inspection.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 18 May 2019).

Why we inspected

We received concerns in relation to environmental risks, infection control and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report. The overall rating for the service has changed from Good to Inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Old Vicarage on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to safe care and treatment, medicines, infection control, staffing, recruitment, governance and reporting procedures at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

People’s experience of using this service:

The service had made improvements since our last inspection and there were no breaches of regulations.

Risks to people’s health and safety had been identified and people felt safe and well looked after. Staff administered medicines as prescribed.

Staff were kind, respectful and caring. They supported people to be as independent as possible.

There were activities and trips outs available for people, and they received care as they preferred.

Staff asked for consent before delivering care. People had access to healthcare professionals when required, and staff followed recommendations when needed.

Staff knew how to care for people and received training in their roles, and support from the management team. Staff supported people to have a range of healthy balanced meals and enough to drink.

The registered manager had clear oversight of the service and supported an effective staff team, who communicated well. The registered manager was approachable and available to people and staff. We found the service had improved and met the characteristics of a “Good” rating in all areas.

More information is available in the full report.

Rating at last inspection: Requires improvement (published 22 May 2018). This service has been rated Requires Improvement at the last two inspections. At the last inspection, there were three breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Why we inspected: This was a planned inspection based on the period since the last report was published by CQC. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions to at least good. They sent us an action plan with this information.

Follow up: We will continue to monitor the service according to our schedule for returning to locations rated Good.

The Old Vicarage accommodates people in individual rooms, each with an en-suite toilet and basin facility, and one had an en-suite shower room. Each floor has some communal bathrooms and further communal toilets. The Old Vicarage is a residential care home for up to 29 older people. It is one of three services owned by the provider Hewitt-Hill Limited, also known as the Ashley Care Group. At the time of our inspection, 26 people were living in the home, which was situated across two floors.

We last inspected this service in January 2017. At that inspection, the service was rated ‘Requires Improvement’ in two areas, which were safe and well-led. The service had not always managed risks associated with certain medicines, and the provider did not have fully effective quality assurance systems in place. The service was rated ‘Good’ in effective, caring and responsive. The overall rating for this service was ‘Requires Improvement’ and therefore we asked the provider to make some improvements to the service. At this inspection in April 2018, we found that the service had not made all of the improvements required and was rated ‘Requires Improvement’ in all areas. There were also three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There was a registered manager in post. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service was not consistently safe for people. This was because risks to people were not always thoroughly assessed and staff did not always have guidance on how to mitigate risks to people. Risk assessments and care plans were not always in place for the safe management of people’s conditions.

Topical medicines were not always administered and recorded consistently, and there was not sufficient guidance for staff on how to administer them. Oral medicines were stored securely and administered safely.

Although there were audits in place, the quality assurance systems did not always identify areas where improvements were needed. The systems in place were not fully effective in monitoring and improving the service.

People did not always receive person-centred care and support in a way that reflected their individual preferences and needs. Care plans did not always contain details of how people wanted to be cared for, and therefore there was not always enough guidance for staff.

People were not always involved and consulted about their care and how they wished to be supported. Staff did not always support people to engage in activities which reflected their interests.

The potential of the environment was not always used to enhance people’s wellbeing. There had been some trips out during the appropriate season, with further trips planned this year in summer.

Staff did not always interact with people appropriately and engage with them effective during their delivery of care. They did not always provide sufficient prompting to eat and drink when needed. There were not always full records of people’s care where they relied on staff for the majority of their daily living tasks such as eating or drinking. Therefore the registered manager did not always have full oversight of whether people were receiving a high standard of care.

Staff received training which supported their roles, however training was not followed up by competency checks. There were employment checks in place which contributed to people’s safety.

People had access to privacy, for example when a healthcare professional needed to see them. Staff knocked on people’s doors before entering, but they did not always behave in a manner that promoted people’s privacy and dignity as much as possible. Staff did not always promote independence.

There was a choice of freshly cooked quality meals available to people, and the cook was aware of who had special diets, and accommodated these. People were able to access healthcare when they needed to.

Staff asked people for consent before delivering care to them, and knew about individuals’ mental capacity. However, records showed that best interests’ decisions had been made without the required mental capacity assessment in place. People were also deprived of their liberty without the required capacity assessments being in place.

The Old Vicarage provides residential care for up to 29 older people. Accommodation is in a period property over two floors which are served by a lift. There are a number of communal areas, including a conservatory, and well maintained gardens. All bedrooms have en suite facilities compromising of a toilet and wash basin. One room has a walk in wet room. At the time of our inspection, 29 people were living at the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in October 2014, we identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach related to non-compliance with the Mental Capacity Act 2005 (MCA). At this inspection, carried out in January 2017, we found that although further improvements were required, the provider had made sufficient progress to no longer be in breach of the regulation.

We have made recommendations to the service about the management of medicines and adherence to the MCA.

There was no evidence that people had come to harm as a result of medicines administration, but due to the service not following current good practice guidance, the risk was present.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Improvements had been made in relation to staff knowledge of the MCA and they had received training. However, the service was not fully adhering to the MCA although no overly restrictive practice was in place.

A newly registered manager was in post who had identified, and begun to rectify, some shortfalls within the service. During our inspection they were open to our feedback and took steps to action our reported concerns promptly.

A quality monitoring system was in place to drive improvement but this had not been wholly effective at identifying concerns in the service. Audits had been completed regularly, at home level, on different areas of the service but they were basic and lacked detail. The provider had not completed any audits since November 2015.

Processes were in place to help reduce the risk of employing unsuitable staff. These included the completion of a police check and obtaining identification. New employees received an induction and their competency to perform their role was assessed and recorded. Staff had received training that was relevant to their work and that would benefit those living at the service.

The service had an open, positive and supportive culture. Staff were happy in their roles and felt supported. They told us they enjoyed working at The Old Vicarage. They worked well as a team and communicated effectively amongst themselves and with others. The home ran smoothly and efficiently.

There were enough staff to meet people’s individual needs and staffing levels were consistent. People told us that they received care and support promptly and staff had time to spend with people.

Staff demonstrated warmth, respect and kindness when supporting people. Humour was used in interactions and laughter was evident during our inspection from staff, visitors and those that used the service. We saw that people’s dignity, privacy and confidentiality were maintained and that staff encouraged choice and independence. Staff gained consent before assisting people with their needs.

Staff had a good understanding of how to prevent, protect, identify and report potential abuse both inside and outside of their organisation. They told us that they had confidence that the service would promptly and appropriately manage any concerns they may have. We saw that the service had reported safeguarding concerns as required.

The individual risks to the people who used the service had been identified and regularly reviewed. Staff had a good knowledge of what these were and what was required to reduce those risks in relation to the care and support they provided. However, there was one occasion where we found that a risk to a person had not been fully assessed and recorded although this was rectified during our visit.

Risks to those working and visiting the home had also been identified, recorded and managed. Regular maintenance and monitoring was in place to reduce those risks. Accidents and incidents were recorded and analysed to identify any patterns or contributing factors in order to reduce future risk.

People had been involved in the planning of their care although written consent was not always in place. Some care plans had been signed by relatives who the service could not be sure had the legal authority to do so. Care plans were individual to people, had been regularly reviewed and were accessible for staff. The content varied between care plans but staff had a good knowledge of the needs and preferences of those they supported.

The service provided activities and events that people enjoyed. They had been designed to meet the needs of those that enjoyed both group and solo activities and for those that liked to remain in their room. The service encouraged people’s relatives and the wider community to join in activities.

People had appropriate and prompt access to healthcare and were involved in decisions around this. Their nutritional needs were met and people who required specialist diets received this. People told us that they had enough to eat and drink and most enjoyed the food provided.

Regular feedback was sought on the service and they were open to suggestions. People reported that the service had made improvements and that the management team were proactive in developing the service. People told us that they would recommend the home.

People were complimentary about the management team. They told us they were approachable, motivated and engaging. They demonstrated a willingness to learn and develop and we had confidence that improvements would continue.

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people who used the service, the staff supporting them and looking at records.

Is the service caring?

People were supported by kind and supportive staff. We observed that staff were patient and understanding when supporting people. We saw staff treating people with respect and with dignity. People told us that the staff were caring. One person said, 'They (the staff) are always polite and kind.' Another person told us, 'The staff are always very kind.'

Is the service responsive?

Staff answered people's call bells quickly when they requested assistance. However, some people's choices were not always responded to. We observed some people were still in bed at 10.30am in the morning. They told us that they had wanted to get up earlier. The staff told us that they did not always have enough staff to assist people to get up when they wanted to.

Although everyone received a main meal, we observed that some people did not receive this in a timely manner. Some people who needed assistance to eat had their meal times interrupted as staff had to assist other people at the same time. This was because there were not enough staff to provide them with the assistance they required over the lunchtime period.

People told us that they enjoyed the activities and entertainment that were offered to them.

Is the service safe?

People told us that they felt safe. Risks to people's personal safety had been assessed and action had been taken to keep people safe where required.

Lifting equipment had been recently serviced to ensure that it was safe to use. The premises looked clean and hygienic and there were no offensive odours evident. However, we were advised that Environmental Health and a Fire Safety Officer had recently inspected the service and found that some areas of the service did not meet current legal requirements. We saw records to confirm this. This was putting people at risk of harm. The provider was aware of this and was taking steps to ensure that the premises were safe.

Is the service effective?

People told us that they were happy with their care and that their needs had been met. All of the people we spoke to said they would recommend the home to others. One person told us 'I am very well looked after.' Another person said, 'I am happy with everything and would recommend this place to anyone.'

We spoke with two visiting healthcare professionals. They told us that the service contacted them quickly when people were unwell or needed specialist attention and that they felt that the communication between them and the service was very good. The staff told us that they felt supported by the management team.

Is the service well led?

The service had a manager who told us that they had been in post since July 2013. We recently received an application from the manager to register with us. This is currently being processed.

Regular staff meetings were held that enabled staff to discuss topics relating to people's care and welfare. People were asked for their feedback on the care they received.

However, we did not see evidence that an effective quality assurance process was in place to monitor the safety of the premises or to ensure that there were enough staff to meet people's needs. The current system had failed to identify a number of shortfalls that had been identified during recent professional inspections.

We spoke with ten people, two visitors and several members of staff. Staff were clear about their responsibilities and showed a good knowledge and understanding of how to meet people's needs. People who used the service told us that staff were kind and always there if they needed help.

We saw that people were relaxed with staff, who listened to their views and concerns. People told us that they would speak with staff if they had a problem or were worried about anything. People told us, "I like it here. Staff are friendly and polite and I feel secure, they know me well.'

We saw people being assisted with their meals. However we observed that two people in their own rooms who had lunch in front of them did not get assistance from staff so their lunch had gone cold.

One visitor told us: 'My relative's every need is catered for and she is very happy", "good ambience, beautiful gardens and views, caring staff and good menu"... and ..."very good selection of entertainment and things to do, no reason for any complaints.'