Archived: The Old Vicarage

We found that some improvements had been made in some areas but that some regulations continued not to be met.

The service was not consistently managing some risks to people's safety effectively. We also witnessed some unsafe practice on the day of our inspection.

Some improvements had been made regarding the control of the risk of the spread of infection. The provider had commissioned an outside healthcare professional to conduct an audit and they were working to complete the actions that had been identified. However, some areas of the service remained unclean and some of the fixtures and fittings were in a poor state of repair which meant that they were difficult to clean to prevent the spread of infection.

The people who used the service did not have access to any secure outside space to aide their health and wellbeing. Some areas within the grounds of the service were unsafe.

Staff had received supervision. However, we were not assured that all staff had received the necessary training to ensure that they provided safe and appropriate care.

The provider had made some improvements in how they monitored the quality of the service. However, we found some areas were not being monitored effectively. This included the completion of staff training and the accuracy of people's care records. Also, a number of the provider's policies and procedures continued to contain out of date information.

We spoke with seven people who used the service, spoke with a visitor, the registered manager and four other members of staff. We also carried out observations, reviewed records relating to the management of the service which included care plans for six of the ten people who used the service, daily records, policies and procedures, staff records and quality assurance monitoring records.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

People who were at risk of developing pressure sores and from poor nutrition and hydration had been assessed. Referrals had been made for advice from a dietician when this was needed. People at high risk of poor nutrition were identified as needing frequent monitoring of their weight and diet. However, this was not always completed as intended so that people were supported safely. We also had concerns that the hoist was not routinely used to transfer people who needed assistance. The wrong sling was selected and another person commented that they did not often see the hoist being used.

The service had improved overall cleanliness since our inspection in February 2014 and staff had completed training in infection control. However, the provider had not acted upon all the findings of the infection control audit they had commissioned by the local NHS infection control team in January 2014. Staff did not always have access to adequate supplies of the disposable gloves they needed to protect themselves and others from the spread of infection. Systems for managing soiled and contaminated laundry were inadequate and increased the risk of infection. However, people told us they were satisfied with the cleanliness of their own rooms. One person told us, 'I'm very fussy. Staff keep it [their room] clean and tidy. I like everything just so.' Another said, 'My bedroom is comfortable and kept nice and clean.' A visitor said that they thought the home was clean and tidy.

Although the provider's Residents Agreement said that people were 'at liberty to make full use of communal areas including the garden' they were not able to do this safely and independently. There was no secure area for people living with dementia and no level and safe pathways.

The Care Quality Commission (CQC) monitors the operation of Deprivation of Liberty Safeguards (DoLS) to ensure people's rights and freedoms are not unnecessarily restricted. Although staff had received introductory training in the Mental Capacity Act 2005 and the DoLS, the manager did not know how to submit an application to the supervisory body if this was required. We were told about a rule for preventing people from going outside the home during the evening, even where they had capacity to make this decision. This could represent a breach of the safeguards which had not been discussed with the supervisory body.

Is the service effective?

A sample of care plans reviewed showed that some people had signed their plans of care when they were developed. For other people, we could see that their relatives were sometimes involved in discussions about their needs.

People's care plans had been reviewed regularly to ensure staff had guidance about meeting people's needs. However, we found that in one of the six care plans reviewed, the service had sought advice from the doctor about a person's needs; there was no indication in their plan of care that any change had been made to take into account this advice. This meant that the process for review was not always robust and effective.

Staff training, supervision and appraisal had improved. This meant that there were opportunities for staff to discuss their work and any development needs they had. There were systems in place to ensure staff had training to enable them to support people effectively.

Is the service caring?

We saw that staff spoke with people in a kind and respectful manner and explained to them what they were doing, for example when preparing to use the hoist. People living at the home spoke positively about the care that staff offered them. One person said, "I can do as I like here. They [staff] are kind to us and let us get up and go to bed when we wish." One person told us, 'I forget things but staff are nice and friendly. They'd do anything for you.' Another person said, 'They're fine. If they weren't, I'd tell them.' 'The staff treat us well and do what they can to help us.' A visitor told us that, 'Staff know how to care.'

Is the service responsive?

People's social and recreational needs were not always met. One person told us, 'We have things to do sometimes. I watch TV most of the time.' We concluded that arrangements to promote people's social and recreational wellbeing did not meet people's needs and preferences. We also found that staff were not always available to respond to people promptly when they became distressed or agitated.

Is the service well-led?

Since our inspection in February 2014, the home had improved systems for monitoring the quality of the service, for example in ensuring that staff training was kept up to date. However, these systems remained insufficiently robust. The checks made had not identified poor record keeping practices or ensured that inconsistencies and omissions in records were addressed, to ensure people received care in the way they needed and preferred.

Action had not been taken promptly where there were shortfalls, for example around managing checks on safety. The system had not identified that emergency lighting and fire detection systems were due for servicing four days before our inspection.

We found that there were no entries showing the options given to people for either lunch or tea, from 16 June 2014 until the day of our inspection on 14 July. One person told us that they were only asked 'sometimes.' They said, 'I chose my lunch this morning. They don't usually ask me. I expect we all have the same then.' People also made comments to us about activities which indicated they were not regularly asked what they would like to see happening in the home. They said they did not particularly enjoy what was on offer. One person said, 'I don't like to do the things and activities they have.' This meant that people's views were not taken into account in the way the service was delivered.

The provider had a history of failing to comply with regulations showing that systems were not robust enough to proactively identify where improvements needed to be made. Where the Care Quality Commission identified that improvements must be made the provider did not always respond in a timely manner.

We found that some improvements had been made but that the provider was still not meeting a number of standards of quality and safety.

We found that staff treated people with dignity and respect and involved them in their care.

People's care needs were assessed but risks to their safety including malnutrition, pressure care and evacuation from the service in an emergency had not always been assessed or plans were not in place to reduce any identified risks.

Some areas of the service were unclean.

Some staff had received an appraisal but there was a lack of formal supervision taking place and there were some gaps in staff training.

The quality assurance programme that was in place was not effective.

Records were stored securely and in the main, were accurate and fit for purpose.

In general, the three people we spoke with during our inspection told us that they were happy with their care and that the staff were caring. We found that some improvements had been made but that six of the standards were still not being fully met.

We saw that people were treated with consideration and respect. However, we did not see evidence that they were fully involved in making decisions about their care.

People's needs had been assessed but these were not always being met. Actions were not always taken to reduce the risk of harm to people. There were a lack of meaningful activities for people to participate in to enhance their wellbeing.

Appropriate checks of the staff being employed by the service were taking place to ensure that they were of good character. However, we did not see evidence that all staff were receiving the appropriate training or supervision to enable them to deliver safe and appropriate care.

The systems that were in place to monitor the quality of the service remained ineffective and some records were inaccurate, undated or not completed. This meant that there was a risk that the people who used the service could receive unsafe or inappropriate care.

We saw on occasions that people were not treated with dignity and respect. The people we spoke with had not been involved in their care. They had limited choice in respect of food, drink and how to spend their time.

People were happy with the care they received. One person told us, 'The staff are very kind and helpful.' Another person said, 'I have a nice room.' A further person said, 'My room is comfortable.' However, one person told us, 'Some staff can be quite abrupt' and that some staff had a, 'lack of understanding.'

We found that some people's needs had not been assessed and that care was not always being delivered to meet their needs or protect them from unsafe or inappropriate care.

Medication was stored securely. However, we could not be assured that it was being administered as prescribed by the prescriber.

Staff told us that they felt supported. However, new staff had not completed a comprehensive induction programme. Existing staff had not received regular appraisals, training or supervision.

The service did not have effective systems in place to monitor the quality of the service it was providing.

We did not speak directly with any people who used the service but looked at records relating to safeguarding and discussed procedures with the manager of the service.