The Old Vicarage

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 assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the service was not always consistently managed and well-led. Leaders and the culture they created did not always promote high-quality, person-centred care. A breach was identified in relation to ensure records were person-centred, and the management and mitigation of risk.

This service scored 61 (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.

Staff and people felt there was a positive culture at the service. Communication channels between people, staff and management were open. A staff member said, “Yes we do (have good staff morale) - it is a good team.”

Leaders did not always have the skills or knowledge required to keep people safe.

The provider and registered manager had not identified several issues we found during the inspection relating to risk assessments, incident analysis and care plans. The registered manager had a good oversight of other aspects of the service. When asked whether the manager was fair and approachable, all the staff we spoke to answered positively.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Policies and procedures were in place to make it easy for staff to speak up. All the staff we spoke to were aware of the process to raise problems and how to contact the provider if they needed to.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. We asked staff whether they had ever experienced discrimination and no concerns were raised with us.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance checks had not identified the issues we found during inspection. This meant some aspects of the governance of the service were not effective.

The provider had taken action to make improvements swiftly following a recent safety incident and had a plan to make further improvements to the service in the future.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. A healthcare partner said, “Our perception is that on the whole staff are warm and engaging, showing genuine concern for residents.” They also explained that at times handovers between staff about the reason for people needing healthcare attention were not always clear. We shared this feedback with the registered manager who confirmed a new process was being implemented to improve this. Other healthcare partners gave positive feedback about interactions with the management team.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider did not always learn lessons from accidents and incidents. Often accidents and incidents were not recorded properly meaning it was difficult to analyse them. This meant people were at risk of preventable accidents or incidents.