Archived: Vicarage House Nursing Home

Vicarage House Nursing Home is a residential care home providing personal and nursing care to 21 people aged 65 and over at the time of the inspection. The service can support up to 32 people.

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

Systems in place to monitor the safety and quality of the service provided failed to identify the shortfalls found in recording of medicine’s and daily records.

The medicines administration records were not always completed effectively. The shortfalls identified included the lack of recording when pain relief patches had been removed and in maintaining safe storage temperatures for medicines. The evidence showed there was a shortfall in the recording of actions taken rather than unsafe practices by staff who had received training and been assessed as competent to safely administer medicines.

People received their medicines in a timely manner and the administration of medicine’s was carried out safely and, in a person, centred way.

Repositioning records had not been completed as required. Repositioning is used to prevent pressure ulcers to people. Food and fluid charts had not been completed to demonstrate when and how much people had been given. We found that people were being repositioned and food and fluids offered regularly however there were shortfalls in recording the information.

People had mixed views about staffing levels in the home. A dependency score based on people’s needs was used to determine how many staff were on duty. However, people said they often had to wait a long time for staff to attend to them. Staff said they felt there were more staff available and that they did not feel rushed. A recruitment programme meant there were more permanent staff and less use of agency staff.

We made a recommendation that the provider looks at ways of deploying staff effectively.

People were 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.

People received care and support that was safe. The provider had a robust recruitment programme and staff had received training in recognising abuse and safeguarding people.

People were supported by a team that was well led. The registered manager demonstrated an open and positive approach to learning and development. Everybody spoken with said they felt the manager was open and approachable

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 8 August 2019).

Why we inspected

We received concerns in relation to the management of medicines and people’s nursing care needs. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well Led section of this report.

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

Enforcement

We have identified one breach in relation to Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Vicarage House Nursing Home is a residential care home providing personal and nursing care to 20 people aged 65 and over at the time of the inspection. The service can support up to 32 people.

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

At the time of the inspection there was not a registered manager in post. A registered manager and provider are legally responsible for how the service is run and for the quality and safety of the care provided. The previous registered manager had left in March 2019. The new manager had applied to become the registered manager immediately on commencing their role and was approved the week after the inspection.

People received care and support that was safe. The provider had a robust recruitment programme and staff had received training in recognising abuse and safeguarding people.

There were enough staff to support people with their daily living and activities. However, although we found staffing levels were in line with people’s assessed needs, comments from some people and staff indicated there were times when they felt more staff would be beneficial. The manager used a dependency tool to determine numbers of staff needed. Staffing was within the suggested numbers identified by the tool. Risk assessments were in place with guidance for staff about how to keep people safe.

People were being supported to have more 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.

People received effective care and support. Staff showed a clear understanding of people’s needs and received training relevant to their role and the needs of people living in the home. People enjoyed a healthy balanced and nutritious diet based on their preferences and health needs.

People received care from staff who were kind and caring. Staff always respected people’s privacy and dignity. However, the manager agreed to improving the provision of fitted toilets in people’s rooms that did not have a partition or screen around. Staff encouraged people to be involved in their care planning and reviews. People were supported to express an opinion about the care provided and were involved in the day to day running of the home.

People received responsive care and support which was personalised to their individual needs and wishes and promoted independence. There was clear guidance for staff on how to support people in line with their personal wishes. Work was being carried out on recording people’s life history’s, likes and dislikes.

People were supported by a team that was now well led. The new manager demonstrated an open and positive approach to learning and development. Everybody spoken with said they felt the manager was open, approachable and they could see that the home had improved. Staff said they felt they were more involved in plans for the future and worked well as a team.

New systems had been put in place to monitor the quality of the service, ensure staff kept up to date with good practice and to seek people’s views. Records showed the service responded to concerns and complaints and learnt from the issues raised. The provider and manager need to show that these improvements can be sustained over time.

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 requires improvement [published 21 June 2018]. At this inspection the service is rated good.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At the last inspection we found Vicarage House Nursing Home required improvement and breaches of the regulations resulted in four requirements. These identified that people were not always treated with dignity and their independence was not always promoted. The service did not always follow a best interest process when people were unable to consent to care and treatment. The service did not have effective systems in place to assess monitor and improve the quality of care provided.

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 service provided.

At this inspection we found there had been an improvement in the quality of care provided however the systems in place were new, the new manager had only been in post for three weeks. Therefore Vicarage House Nursing Home continues to be rated requires improvement so that the improvements in place can be seen to be consistently effective.

Vicarage House Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide personal care and accommodation to up to 32 people who are frail or living with dementia. Accommodation is provided in a converted residential dwelling over two floors. At the time of our inspection 27 people were using the service.

There was no registered manager in post however the new manager was in the process or applying to be registered with the Care Quality Commission. 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.

There were processes and practices in place to keep people safe. People told us they felt safe living in Vicarage House Nursing Home and with the staff who supported them. However some relatives said they were concerned about the number of new managers recently and were, “Keeping an eye on the changes to ensure their family member remained safe”.

There were systems in place to ensure the management and administration of medicines was safe and protected people from harm. The provider’s recruitment policy protected people from possible harm from the employment of inappropriate staff.

People received effective care and support because staff understood their personal needs and abilities. Staff had the skills and knowledge to meet people’s needs. The provider had a programme of training which ensured staff had up-to-date guidance and information. The new manager explained they had also introduced other training which was specific to the needs of people living in the home.

People told us they were always consulted fully before any care and support was carried out. Staff were supported to develop their skills through training, staff meetings and one-to-one conversations. The new manager told us, and all staff spoken with confirmed, that they had carried out one-to-one meetings with all members of staff. This meant they had identified areas for training and development and areas of interest for staff to be involved in in the future.

Most of the people spoken with said they received care and support from staff who were polite and kind. One person said, “The staff are always very caring and very polite”. However another person told us that about 10 months ago they did not feel a member of staff was very caring or polite towards them. They continued to add that things had improved and they were happy now.

Since the last inspection the activities organiser had been promoted to a full-time post. They were working with the new manager to introduce a full programme of meaningful activities for people to take part in. They were in the process of building up further relationships within the village. Children visited the home to read to people living there, and there were arrangements in place for people to visit the school once a month to have lunch with the children. The activities organiser confirmed that they were in the process of obtaining a minibus and improving the outside areas. A meet and greet tea party had been arranged for families to meet the new manager. When we returned in May people told us about the garden party they had had to celebrate the royal wedding.

The new manager had been in post for three weeks prior to the first day of the inspection. They had already identified areas for improvement and had introduced new working procedures and training for staff. Systems in place to monitor the quality the service had identified where there were shortfalls and they had implemented changes to drive improvement. It was evident that a lot of hard work had been carried out by the new manager, deputy manager and staff to ensure the experiences for people living in Vicarage House Nursing Home continued to improve.

The last comprehensive inspection of the home was carried out on 30 September and 05 October 2015. At that time there was a new manager in post who had not yet been registered. There had previously been breaches of regulation concerning record keeping relating to people's care, recruitment, and quality assurance. We found the new manager had implemented changes which had improved these and other aspects of the service, however they needed to prove these changes could be consistently maintained. Although we found no breaches of regulation at the inspection on 30 September and 05 October 2015, the home was rated ‘Requires Improvement’ because we identified further concerns about staff training and the involvement of people in the day to day running of the home.

We carried out an additional focussed inspection on 21 April 2016 to look at safeguarding concerns related to a lack of staff training and knowledge in the moving and handling of people, and the failure of staff to respond to people’s changing needs. We found all staff had received training in moving and handling people and were using moving and handling equipment correctly. We also found staff were responsive to the changing needs of people in the home.

At this comprehensive inspection in November 2016 we checked whether improvements had been made since the last comprehensive inspection in September 2015. We found that while some improvements had been made, they were not always effective. We identified additional areas of concern.

There was a risk that people might not receive safe care, because risks to their health and welfare had not always been accurately assessed, recorded or reviewed. This meant staff did not have access to up to date written information about potential risks or the actions they must take to reduce those risks. Care plans did not provide the guidance staff needed to provide safe, effective, personalised care. This lack of information increased the risks for people, particularly if staff were less familiar with the person, for example if a person without the capacity to understand the risks, refused to be supported by care staff, or had communication difficulties due to sensory loss.

The systems in place for the administration of medicines were not safe, which put people at risk. The medicines policy did not cover all the required areas and failed to comply with current legislation and guidance for medicines administration. Medicine Administration Records (MAR) were handwritten, unclear and did not always contain the information needed to administer medicines accurately and safely.

Staff training related to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), needed to improve so that people’s legal rights could be fully protected. Some people had restrictions in place, such as bed rails, but there had been no consideration of whether these restrictions were in their best interests. In addition some ‘blanket’ capacity assessments had been made relating to people’s ability to make decisions, rather than a specific decision, which indicates the MCA was not well understood. We also found people were potentially being deprived of their liberty, but had not been referred for assessment.

During the inspection we found that although some staff were kind and caring when supporting people, the ‘person centred’ values expressed by the registered manager were not consistently put into practice. Much of the care we observed in communal areas was ‘task focussed’, and people and relatives confirmed staff rarely spent time chatting with people in the lounges unless they were taking them to the toilet or giving them their meals. People and relatives told us staff didn’t take people to the toilet frequently enough which they found undignified. One person told us, “You do have to wait a long time when you need to use the loo; you have to call out or bang your table. It can be annoying.” Staff did not always promote people’s independence, for example giving a person with poor sight access to a call bell, so they could ask for the support they needed to move around.

People were not fully protected from risks to their health and safety because the provider’s quality assurance system had failed to identify some potential risks. Although audits were carried out related to the environment, accidents and incidents and pressure sores, the provider had not identified that risks to people’s health and welfare had not always been accurately assessed, recorded or reviewed, or that care plans did not provide the guidance staff needed to support people effectively. They had not recognised that the systems in place for the administration of medicines were not safe, or that people’s legal rights were not being protected.

Although the home was well staffed, they were not deployed effectively. People and relatives told us staff rarely spent time chatting with them in the lounges unless they were taking them to the toilet or giving them their meals. One person told us, “There are plenty of staff around, but it is hard to get their attention when needed”.

Following the inspection in September 2015 the registered manager had introduced a ‘friends of Vicarage House’ group, a ‘suggestion box’ and customer feedback questionnaire, to better involve people in the day to day running of the home. However, despite this the people living at Vicarage House told us they did not remember being asked for their opinion about the day to day running of the home and had not attended any meetings there. Some people expressed dissatisfaction with some aspects of life at Vicarage House, which the registered manager had not been aware of. This indicates that the service needs to be more proactive in supporting people to make a meaningful contribution to the running of the home, and to express their views, particularly if they are living with dementia or sensory loss.

A supervision programme had been introduced in September 2015 to provide an opportunity for staff to spend time with a more senior member of staff to discuss their work, and highlight any training or development needs. These supervision meetings were also a chance for any poor practice or concerns to be discussed. However, this programme was not in place when we inspected in November 2016. Immediately following the inspection the registered manager informed us that staff supervision was now in place.

Following the inspection in September 2015 the registered manager had implemented a staff training programme.

The staffing structure in the home provided clear lines of accountability and responsibility. There was now 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. There was always a registered nurse on duty which made sure people and staff always had access to a more senior staff member to oversee people’s health needs and respond to any concerns. Care staff demonstrated a good understanding of people’s physical care needs. We observed staff caring for people in a safe way, for example they were using moving and handling equipment correctly, explaining to the person what they were doing, and providing assurances while they were moving them.

People were protected from the risk of abuse through the provision of policies, procedures, robust recruitment and staff training.

People’s needs were assessed before moving into the home to determine whether the service was right for them and able to meet their needs. This included their individual nutritional requirements and preferences, and interests, to ensure they received a service appropriate to their needs and wishes.

The registered manager was working to expand the activities available through the recent recruitment of two activity co-ordinators and the development of community links.

People were supported to maintain ongoing relationships with their families and friends. Relatives told us they were kept informed about the well-being of their family member, and were fully involved in reviews of their care.

The service was able to provide effective care to people at the end of their lives. People’s end of life wishes were discussed with the person and their family and documented. This meant staff and professionals would know what the person’s wishes were and could ensure they were respected.

We recommend that the service seek advice and guidance from a reputable source about effective systems of staff deployment.

We have made a further recommendation that the service seek advice and guidance from a reputable source, about the meaningful involvement of people in decisions about the day to day running of the home.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

The last inspection of the home was carried out on 30 September and 05 October 2015. At that time we found some staff training had not been carried out however dates had been booked. People were not always involved in the day to day running of the home. There was no registered manager in post. We found the new manager had implemented changes which they needed to prove they could maintain consistently. This report only covers our findings in relation to the recent safeguarding concerns we received. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Vicarage House Nursing Home on our website at www.cqc.org.uk.

Vicarage House Nursing Home is registered to provide care and accommodation for up to 32 older people. There were 31 people living in the home at the time of the inspection.

There is 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.

One concern received before this inspection stated staff had not received training in how to safely move people when they were unable to stand or mobilise and used incorrect and unsafe moving techniques. The concerns also stated staff had not received training in the correct use of equipment provided to lift and move people.

At this inspection we found all staff had received training in moving and handling people. Records showed, and staff confirmed, training had been carried out in the correct procedures to follow and the correct use of moving equipment. During the inspection we observed staff using equipment to lift people who were immobile. We saw they followed the correct procedures and used lifting equipment safely and appropriately.

Before this inspection we also received concerns that the changing needs of people had not been noted and as a result a hospital admission was delayed.

At this inspection we found staff were responsive to the changing needs of people in the home. Records showed people’s needs were assessed and reviewed regularly with referrals being made to health care professionals when necessary. We found people were referred to specialist clinicians and to the hospital if assessed as needed. People’s care plans included advance decisions such as if they wanted to be admitted to hospital if their health deteriorated and if they wished to be resuscitated in the event of a cardiac failure. Staff were also aware people and relatives had the right to change their minds about any advance decision made.

Improvements are required to some aspects of record keeping in the home. Records seen did not always reflect the safe and appropriate care we saw or the attention to safe recruitment of staff.

The focus of the inspection was to answer five key questions: Is the service safe, effective, caring, responsive and well led? This was a summary of what we found:

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe. People told us staff answered their bells promptly and came to their assistance during the day and night. One person told us "Of course we feel safe here. We have friends 'outside' who visit often. We can talk to matron and there are always nurses on duty."

Systems were in place to make sure managers and staff learnt from events such as accidents, incidents, concerns and investigations. This reduced the risks to people and helped the service to continually improve. The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards which applies in care homes. Nobody in the home was subject to a DOLS order at the time of the inspection. The home had policies in place and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The manager had undertaken training in safeguarding adults and implementing the Mental Capacity Act in 2013.

The service was safe, clean and hygienic. Staff understood how to reduce the risks of infection through routine cleaning and use of thorough hand cleansing. Equipment was well maintained and serviced.

The manager had day to day contact with people in the home. They set the staff rotas and took people's needs into account when making decisions about the numbers, qualifications skills and experience required.

Recruitment practice was safe and thorough although some improvements with record keeping were required. No staff had been subject to a disciplinary action. Policies and procedures were in place to make sure unsafe practice was identified and people were protected.

Is the service effective?

People's health and care needs were assessed with them, and they were involved in compiling their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

We saw records indicated people admitted to the home with pressure damage. Their skin improved and . Action was taken to effectively reduce the incidence of falls for one person. People who were frail received kind, appropriate and respectful care that met their needs and maintained their health as far as possible.

People's needs were taken into account with the layout of the home enabling people to move around freely and safely. The premises had been adapted to meet the needs of people with physical impairments within the limits of the older part of the house. People confirmed they were able to see their visitors in private and visiting times were flexible. We discussed with the manager the design of some of the en-suite facilities and the importance of people being able to make choices about the suitability of their rooms.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People we spoke with were satisfied with the care they received at the home. One person told us 'I am very happy here. If I didn't like it I would have gone.' Another person said 'I get all the help I need and certainly have no complaints.'

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.We saw one of the people who were cared for in bed. We noted they appeared warm and comfortable. They had a call bell within reach to enable them to summon help if they required it. We saw the manager approach the person to adjust their pillows. They were clearly very pleased to see the manager and very relaxed and happy with the attention they received.

Is the service responsive?

The service recognised people wanted to live their lives in different ways and supported them to do so. Some people enjoyed being part of the home community while others preferred the peace and quiet of their own rooms.

People knew how to make a complaint if they were unhappy. Relatives told us the manager kept them informed. One relative told us they were '300%' satisfied with the care their family member received. We saw an incident when a relative had not been satisfied was dealt with formally. People said that they were able to raise issues "at any time" with the manager.

Is the service well-led?

The service had a manager who was registered with the Commission. The service was well led because the manager was responsive and accessible to people in the home. They knew the people who lived in the home very well and were committed to their well-being and care. The service worked with other agencies and services to make sure people received their care in a joined up way. The service identified shortfalls in the service and addressed them promptly although some aspects of record keeping needed to be improved. As a result the quality of the service was continuingly improving.

You can see our judgements on the front page of this report.

We observed that people's privacy and dignity were respected and that they were included in making decisions about their care. They were encouraged to be as independent as possible and their families were encouraged to spend time with them.

There was a team of committed staff who provided a sensitive and caring service. They demonstrated a good understanding of the needs and wishes of residents and their families and created a friendly and welcoming environment. However, the process for recruiting and selecting staff was haphazard and record keeping was ineffective.

There was a system for monitoring the quality of clinical care but there was no evidence that policies and support services had been monitored. There were few risk assessments or action plans to address or reduce risk.

During this inspection we found that the registered manager had worked with outside agencies to review their care plans. They had introduced a care plan system that was person centred and included associated risks and control measures.

During this inspection we also reviewed the management of medication. We had received information of concern that medication was not being managed appropriately.

We found that the receipt, storage and administration of medication was managed safely within the Royal Pharmaceutical Society guidelines.

We did not speak to people who lived in the home during this visit. However at the last inspection on 30 July 2012 people told us they were happy with the care and support they received. One person told us they would have preferred to be in their own home but, "they are very good you're kept clean and tidy". They confirmed to us that they preferred to remain in their own room but knew activities were available. Another person told us, "I like it here; I wouldn't want to go anywhere else". They also confirmed they enjoyed the food and said, "Staff are very good and if I had any concerns I would talk to matron".