Vicarage Residential Home

Vicarage Residential Home is a residential care home providing accommodation and personal care for up to 35 people. The service supports people who may need support with their physical and mental health and may be living with a dementia. Vicarage Residential Home is an adapted building. At the time of the inspection there were 29 people living at the service.

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

People told us they were happy with the care they received, and people said they felt safe living there. Comments from people included; “Oh yes, I feel safe here.” Another person said; “I’m spoilt and have lovely staff who look after me well.” While a relative commented in a survey returned; “The care is fantastic.” While a professional commented on a survey about the service; “Well impressed.” People looked relaxed, happy and comfortable with staff supporting them. Staff were caring and spent time chatting with people as they moved around the service.

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 were supported by staff who completed an induction, training and were supervised. Staff were recruited safely in sufficient numbers to ensure people’s needs were met. There was time for people to have social interaction and there was a designated activities staff member to assist people. Staff knew how to keep people safe from harm.

Staff received appropriate training and support to enable them to carry out their role safely, including fire safety and mental health training. However, we have recommended that the training matrix reflects the updated staff training completed.

The environment was safe and there was equipment available to support staff in providing safe care and support. Health and safety checks of the environment and equipment were in place.

There were processes in place to prevent and control infection at the service including additional cleaning and safe visiting precautions.

People were supported to access healthcare services, staff recognised changes in people's health, and sought professional advice appropriately.

Records of people's care were individualised and reflected each person’s needs and preferences. Risks were identified, and staff had guidance to help them support people to reduce the risk of avoidable harm. People’s communication needs were identified, and where they wanted, people had end of life wishes explored and recorded.

People were involved in menu planning and staff encouraged them to eat a well-balanced diet and make healthy eating choices. Special diets were catered for. One person said; “Always something I can have if I don’t like something offered.”

People were supported by a service that was well managed. Records were accessible and up to date. The management and staff knew people well and worked together to help ensure people received a good service.

Staff told us the registered manager and management team was available and assisted them daily. They went onto say how they were approachable and listened when any concerns or ideas were raised. One staff member said; “Never been in a place like it! Love it!”

People and their families were provided with information about how to make a complaint and details of the complaint’s procedure were displayed at the service.

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

Rating at last inspection and update

The last rating for this service was good, published on 3 May 2018.

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding.

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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

There was a registered manager at the service. They were supported by a deputy manager. Both had worked at the service for many years. 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. People and relatives said of the management team, “All the staff are very approachable", “This place is a home from home", “The managers are as good as gold", “It’s the best home I've stayed in" and “The staff and management are excellent. There's good communication from them, they always phone if something is wrong. I have peace of mind."

Following the last inspection in March 2017, we met with the provider to discuss the concerns raised at the last inspection because we had rated the service as requires improvement overall. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, responsive and well led to at least good. There were concerns about safe recruitment of staff, adequate staffing levels at night, the admission assessment process and the effectiveness of quality assurance processes.

During this inspection in March 2018, we found all concerns had been addressed and we rated the service as good in all domains and overall. At this inspection we found the service was meeting all regulatory requirements and we did not identify any concerns with the care provided to people living at the home.

On the day of the inspection there was a calm and relaxed atmosphere in the home and we saw staff interacted with people in a friendly and respectful way. People were able to choose what they wanted to do and enjoyed spending time with the staff who were visible and attentive. There was a lot of staff interaction and engagement with people, some of whom were living with dementia and unable to tell us directly about their experiences. They looked comfortable and happy to spend time in the large lounge/conservatory or choose to spend time in their rooms. People were encouraged and supported to maintain their independence. There was a sense of purpose as people engaged with staff, watched what was going on, played games and pottered around the home. Staff engaged with people in ways which reflected people's individual needs and understanding, ensuring people mobilised safely from a discreet distance.

People were provided with good opportunities for activities, engagement and trips out. People could choose to take part if they wished and when some people preferred to stay in their rooms, staff checked them regularly spending one to one time with them.

People and relatives said the home was a safe place for them to live. Comments included, “They make sure mum always has her call bell on hand", “They stay and make sure I have taken my medication", “I have my door open so the staff can see I am safe and ok” and “The staff are so kind, they make me feel safe." Staff had received training in how to recognise and report abuse. All were clear about how to report any concerns. Staff were confident that any allegations made would be fully investigated to ensure people were protected. Any safeguarding concerns had been managed well with provider involvement, and the service worked openly with the local authority safeguarding team. Relatives said they would speak with staff if they had any concerns and issues would be addressed, and people seemed happy to go over to staff and indicate if they needed any assistance. Staff were vigilant about protecting each person from possible negative interactions with other people living at the home, recognising frustrations and misunderstandings between people due to them living with dementia. They used chatting and distraction techniques as they knew people well, showing patience and understanding.

People and relatives knew how to make a formal complaint if they needed to but felt that issues would usually be resolved informally.

People were well cared for, and people and relatives were involved in planning and reviewing their care as much as they wanted to be. Staff demonstrated kindness and compassion for people through their conversations and interactions. If people found it difficult to communicate or express themselves, staff offered additional support and showed patience and understanding. People’s equality and diversity was respected and people were supported in the way they wanted to be. People's human rights were protected because the registered manager and staff had an understanding of the Mental Capacity Act 2005 (MCA).

There were regular reviews of people's health, and staff responded promptly to changes in need. For example, care records showed many examples of staff identifying changes in need and appropriate and timely referrals to health professionals.

People were assisted to attend appointments with appropriate health and social care professionals to ensure they received treatment and support for their specific needs.

Medicines were well managed and administered using a computer system. They were stored in line with national guidance. Records were completed with no gaps, and there were very regular audits of medication records and administration to help ensure the correct medication stock levels were in place.

Staff had good knowledge of people, including their needs and preferences. Computerised care plans were individualised and comprehensive ensuring staff had up to date information in order to meet people's individual needs effectively. Handover and communication between staff shifts was good so there was consistent care. The service rarely used agency staff but were usually able to fill shift vacancies within the staff team.

Staff were well trained and there were good opportunities for on-going training and obtaining additional qualifications. The staff team was stable and many care staff had worked at the home for some years. Staff clearly had good knowledge in identifying people’s changing needs and providing appropriate care. People and relatives’ comments included, “All the care I receive is wonderful”, “They [staff] even brought me a cup of tea at 4am because I was wide awake", “If you need anything, they just get it for you" and “They are sympathetic towards mum's needs”.

People's privacy was respected. Staff ensured people kept in touch with family and friends, inviting friends and family to outings and events regularly. People were able to see their visitors in communal areas or in private.

The registered manager and deputy manager showed great enthusiasm in wanting to provide the best level of care possible and valued their staff team. For example, organising staff team outings and working together to ensure people’s needs were met as well as facilitating fun opportunities for people. Staff had clearly adopted the same ethos and enthusiasm and this showed in the way they cared for people in individualised ways. Staff were positive about working at the home.

Observations of meal times showed these to be a positive experience, with people being supported to eat a meal of their choice where they chose to eat it. The cook dished out individual plates from a hot trolley and clearly knew what food people personally enjoyed. Staff engaged in conversation with people and encouraged them throughout the meal, noting who liked to sit with whom. Nutritional assessments were in place and robust monitoring to ensure people were encouraged to have a balanced diet. Special dietary needs were catered for as well as specialist crockery and cutlery.

There were now effective quality assurance processes in place to monitor care and plan on-going improvements overseen by regular provider audits and topical surveys. During the inspection, a food survey was being completed to enable people to add items they liked to the menu.

There were systems in place to share information and seek people's views about the running of the home, including relatives and stakeholders. All responses were positive from the recent quality assurance questionnaire. People's views were acted upon where possible and practical, and included those living with dementia. Their views were valued and they were able to have meaningful input into the running of the home, such as activities they would like to do, which mattered to them.

The Vicarage Residential Home is registered to accommodate a maximum of 35 older persons. They provide residential care without nursing. Nursing care if needed is provided from the community team. There were 33 people living at the service when we visited. The Vicarage also provided short term respite care for people.

The service had 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 the last inspection on the 23 June 2016 we found some concerns and areas where improvement was needed. We found medicines were not always managed safely, and people did not always receive their medicines at the time they needed them. The number of staff available were not sufficient to meet people’s needs safely. People also told us there were limited opportunities or activities available to occupy their time, and we were told the service was not always well- led. The provider wrote to us and told us how they planned to address these concerns and by when. We found at this inspection that improvements had been made in relation to activities and the management of people’s medicines. However, improvements were still needed in relation to staffing, and the leadership of the service.

Although the registered manager and provider told us action had been taken to address concerns relating to staffing, people and staff still said there were still times when staffing at night was not sufficient to meet people’s needs and to keep them safe. The registered provider and registered manager told us staffing levels had been increased when the number of people in the home increased. However, we saw no evidence of an effective system to review staffing levels regularly based on people’s needs.

People were supported by staff who had undergone sufficient checks before starting work in the home. However, people were not fully protected as systems were not sufficient to monitor and address risks, which had been identified in relation to staff supporting them.

The registered manager and provider undertook a range of audits to assess and monitor the quality of the service. They said they also met with people and staff regularly to discuss any issues and improvements required. However, these had not in all cases been effective in identifying shortfalls and gaps in staffing and records. Following the inspection the registered manager wrote to us and told us how they had improved the quality auditing process to include regular reviews and monitoring of staffing levels.

People told us about the different activities now available and an activities coordinator had been employed to improve the social opportunities available to people. However, information in people’s support plans about their backgrounds and interests had not always been completed, which could mean this information was not known to staff planning their care.

The admissions process required some improvement to help ensure people received consistent care as they moved between services. When people were admitted from hospital information had not always been gathered in relation to other aspects of their life, such as where they had previously lived. The absence of this information could mean important issues relating to people’s life and lifestyle would not be known or form part of their on-going plan of care.

Healthcare professionals said the registered manager and staff had worked hard to improve links between the home and healthcare professionals. They said the registered manager and staff had listened to advice and had improved records, communication and staff training. This had resulted in people’s health care needs being more appropriately met by the home and healthcare services.

People had their medicines managed safely. People received their medicines as prescribed and on time. People were supported to maintain good health through regular access to health and social care professionals such as GPs, social workers, district nurses and physiotherapists. Health professionals within the district nursing services spoke highly of the service. They said the staff team made appropriate and prompt referrals as well as working alongside them during visits to better understand and respond to people’s healthcare needs.

On the day of the inspection staff within the service were relaxed, there was a calm and friendly atmosphere. Everybody had a clear role and information we requested was supplied promptly. Records relating to people’s care and the service were well organised and easy to follow. Staff knew people well and were able to tell us about people’s needs and how they chose and preferred to be supported. People were comfortable with staff and we observed positive interactions between people and staff supporting them. We met relatives visiting their loved ones and they told us they were always welcomed and able to visit at any time.

People said the food in the service was good and they were offered choice and plenty of snacks and drinks throughout the day. Staff were aware of risks associated with people’s diet and clear guidelines were in place to minimise risks and to help ensure people had a good mealtime experience.

People we observed were safe. Checks were undertaken of the environment and equipment to help ensure it remains safe and fit for purpose. All staff had undertaken training on safeguarding adults from abuse and had the information and knowledge needed to report any concerns.

People's risks were managed well and monitored. Staff demonstrated a good understanding of the Mental Capacity Act (2005) and understood when people had the capacity to make decisions for themselves or if best interest meetings and the involvement of others were required. Families were involved in decision making where necessary.

People were supported by staff who had undergone a comprehensive induction programme and on-going training relevant to the needs of people being supported. Staff said they felt well supported by the registered manager and deputy manager and had opportunities for discussion and to reflect on practice.

The registered provider and registered manager were visible in the home throughout the inspection. When the registered manager was not working in the home they were on call and available to be contacted by staff. The registered provider spent time in the home talking to people, and listening to their views about the service. People said they felt the some aspects of the service had improved, such as décor and availability of management. The registered manager undertook spot checks of the environment as well as a range of audits such as medicines, records, equipment and people’s personal finances. Systems were in place to record and analyse incidents and these processes had allowed prompt action to be taken when concerns and changes in people’s needs had been identified.

We found breaches in the regulations. You can see what action we told the provider to take at the back of the full version of this report.

Vicarage Residential Home is registered to accommodate a maximum of 35 older persons. They provide residential care without nursing. Nursing is provided from the community nursing team as required. There were 31 people living at the service when we visited.

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.

There were not sufficient staff on duty at all times to ensure people’s needs were met. All staff we spoke with during the inspection expressed concerns about the staffing levels over recent months, particularly at night. Staff had been covering cooking, cleaning and laundry duties due to vacancies and sickness. However, five new staff were going through recruitment checks which would ease some of the staffing issues we found. We spoke to the registered manager about people’s and staffs feedback and following the inspection were advised a meeting with the providers had been arranged to discuss safe staffing levels.

People’s prescribed medicines were largely administered as prescribed. However, the service was piloting a new electronic medicine system which was causing some difficulties affecting people receiving their medicine safely. The registered manager was working to resolve issues and make improvements.

People told us activities were limited. Most people had little meaningful stimulation throughout the day. Staff told us they did not have time to do activities with people. The registered manger told us with budgetary cuts, providing individualised activities was not possible. This was an area he and the provider wanted to improve.

The home was clean and infection control procedures were followed. Some areas of the home had an odour but the registered manager was taking action to address this. Staff told us they were unable to keep up with the laundry duties. The registered manager was aware of staff concerns and was taking action to increase the laundry facilities to support staff.

Staff treated people with kindness and respect. We observed staff treating people with patience and supporting people in their own time. People were complimentary about staff and how they treated them. They also confirmed staff always asked for their consent before commencing any care. Staff always protected people’s dignity while delivering personal care. People unable to consent to their care were being assessed in line with the Mental Capacity Act 2005.

Staff were recruited safely and underwent training to ensure they could effectively meet people’s needs. New staff underwent an induction and shadowed experienced staff. Staff were knowledgeable about identifying safeguarding concerns and understood how to raise concerns. All staff we spoke with stated they would raise these with the registered manager and felt they would be addressed. If not, they felt able to whistle blow and knew who to contact if this was required.

People and staff felt they could raise any concerns or issues about the standard of care or suggest changes about the service. The registered manager had systems in place to identify people’s concerns or complaints.

The provider and registered manager regularly checked the quality of the service to ensure standards were being maintained to an appropriate level. A number of audits were completed to measure this. People and staff were asked for their views.

CQC decided to issue a notice to deregister the then registered manager. The registered manager deregistered with CQC so no further action could be taken.

We are therefore satisfied that the concerns were addressed.

We considered our inspection findings to answer the question

Is the service safe?

This inspection was carried out to assess how medicines were handled and managed in the home. This was to follow up on some issues that were found at a previous inspection.

This is a summary of what we found-

Is the service safe?

We found that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. Improvements had been made since our previous inspection and medicines were now handled and managed safely.

Our team was made up of two inspectors, a pharmacist inspector and an expert by experience (who was a lay person with knowledge of care homes). We spent the day at the home and spoke with people who lived in the home, visitors, staff, professionals with knowledge of the home and the manager running the home. We also read paperwork detailing people's care (called care plans) and the running of the home.

There were 34 people living at the home when we visited.

As part of our inspections we look to see that the service is

' Safe

' Effective

' Caring

' Responsive

' Well led

A summary of what we found can be found below.

Is the home safe?

During our previous visits in 2013 we raised serious concerns about how safe people were in the home. When we visited this time we found there had been a high level of improvement in this area.

We were told 'I feel safe here, I've never known such kindness.'

We found the home had active and up to date policies in place to ensure people were protected from the risk of harm. Staff had undergone relevant training, supervision and appraisal. For example, staff were trained in safeguarding vulnerable adults. People told us they felt safe and would speak to the manager if they had an issue or concern.

We saw the home involved people in the running of the home and sought their view or opinion of their care. We saw that other issues were due to be discussed at a forthcoming residents' meeting.

People's care needs were reflected in their care plans and people told us their needs were being met. The documentation of this care was clear and up to date. There were regular reviews and risk assessments completed to ensure people's needs continued to be met. Visitors and professionals also told us they felt people were safe and well cared for.

We have concerns in respect of the safe administration of medicines that we judged were having a minor impact on people. We have asked the provider to provide an action plan and date when they will have addressed the concerns.

We found the home was aware of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) and were seeking a review of all people who did not have the capacity to consent to their care. Following national changes to DOLs they were applying to the local authority following our visit.

Is the home effective?

We found that the care planning system in place demonstrated that the home was effective in delivering care that met people's assessed needs.

People were involved in running the home and had been instrumental in setting up a residents' fund and summer fete.

Staff were well supported and trained. They were able to relate how they were meeting people's needs and fulfilling their care role.

Is the home caring?

We saw that the staff related to people with care and kindness. Humour was used carefully and appropriately.

We found that people were treated with respect and were addressed by their chosen form.

People told us 'The food is lovely, I have a choice of food and I get help at mealtimes as it is difficult for me to feed myself', 'I can have a bath whenever I want one, my hair is done every week and I see the chiropodist monthly', 'My privacy is respected', 'I can't fault the home or the staff, we have no complaints' and 'I consider the care staff friends of mine.'

Is the home responsive?

Following our visits to the home in 2013 we were in contact with the home regularly. We found that the home was responsive to the concerns and responded to requests for information from both the local authority and the Care Quality Commission. For example, they sent us an updated action plan in January 2014 so we could ensure progress was being made and maintained.

We found that people's care plans and risk assessments were regularly reviewed. When concerns were raised we saw that people's needs were assessed. For example, we saw that people had been reviewed by district nurses, occupational health and their GP.

On the day we visited the home had one less care worker than planned on duty in the day. We saw that senior staff and the manager were on the floor supporting care and various visiting professionals. Where people's care was delayed we found that people were being told and updated.

People told us they were able to rise and retire as they desired. One person told us they had been moved to a room in a more sociable area of the home when they requested it. They told us how this had reduced their feelings of isolation. They told us they had also requested their bedroom door be left open so they could make the most of the opportunities to speak to staff and other people in the home.

Professionals we spoke with told us they found the staff to be knowledgeable of people's needs and always able to respond to questions. A paramedic attending the home the day we visited told us they were impressed by the staff member who supported them stating 'There was a sense of everything being under control.'

Is the home well led?

When we visited the home in 2013 we raised serious concerns about how the home was being run. When we visited this time we found there had been improvement in this area.

On the day we visited there was a manager, a deputy and senior carer on duty. This was extra to the care staff delivering day to day care. We found there was a clear staffing structure in place. Staff both told us they felt the manager was approachable. Most people told us they felt the home to be run well and better than before. The GP told us the home had 'Undergone a lot of transition but was getting better. There is a lot more policy and structure in place.' One resident told us they preferred the previous manager, but everyone else we spoke with told us they felt the home to be well led.

We found that the home had put in place a comprehensive list of policies, procedures and practices to ensure the quality of care was built on a foundation. The associated audits ensured this was maintained. For example, we found that the care plans were reviewed monthly and the associated risk assessments and paperwork updated as required.

We heard 'I can't fault the home or the staff, we have no complaints', 'I live abroad and visit whenever I can; I feel that Mum is getting good care.'

The main concern people raised with us was their not being involved in the planning of the menu and the delay it took for food to be transferred from the kitchen to the dining room. We were told this would be addressed at the next residents' meeting due to take place two weeks following our visit.

There was not a Registered Manager currently in place. We discussed this with the current manager during our visit and were assured that this would be an action they would complete as soon as possible.

The previous manager is no longer in post at the home and a new manager and deputy have been appointed. We met with the new manager on 30 September 2013 and requested a new, refined action plan with dates when they believed they were going to be able to put things right. We were told the final date for completion of the actions required would be 10 November 2013. This was in respect of introducing a new care planning system. They told us they had already addressed many of the concerns in many areas we had identified in August.

Our visit to the home on 14 October 2013 was carried out to check on the progress against the action plan and to ensure that we were satisfied that progress was being made and people's welfare needs were being met while the planned changes were being implemented. We also, wanted to speak to the people living in the home, family members and health and social care professionals with knowledge of the service to ensure they felt that the situation was improving.

We found there had been improvement in each of the 11 areas of concern we reviewed during this visit. We judged the management of medicines and record keeping at the same level as when we visited in August 2013 as they had yet to reduce our concerns sufficiently in those areas. We found the progress in respect of diet and nutrition, staffing levels, how staff were recruited and notifications of other incidents were now met and our concerns alleviated.

People and family told us they felt the home had improved and voiced their confidence in the new manager and deputy manager. People told us they were happy with their care and family members told us that even though they had considered moving their family members when the concerns arose they were happy they had not done so.

We found that there were regular resident's meetings and annual questionnaires sent out and people felt able to raise issues and these were looked into.

We saw that care staff spoke to people with respect but care staff were not always involved with people. People told us that the care staff were very busy and there was not enough staff at times.

People told us they felt their dignity was respected during personal care however we found that people's dignity was not always respected.

We saw that people's care plans and the care given was inconsistent and the daily records did not reflect how people's welfare was managed or advice sought from medical professionals.

We saw that people were not having the correct diet, sufficient fluids and people were going for long periods of time without fluid and nutrition. People requiring support to eat were not helped and their weight was not routinely recorded and concerns actioned.

We found that people were not being safeguarded in the home and there were concerns about the storage and administration of medication.

The home was not effectively managed and staff were not recruited or trained safely. We found that there were insufficient processes in place to ensure the quality of the home.

We found that people who used the service were informed about the care planned for them and they felt able to be part of the care planning process. Care records showed that people had signed to state that they agreed to care given. Care records were well maintained and reflected current care given.

Although the home was in need of refurbishment and plans for this were due to commence, the home was clean. There was an infection control policy in place which reflected current guidance. A small team of cleaners maintained the home which was odour free in most parts. Staff were well supervised and had been employed at the home for a long time. The newest member of staff had been employed for over one year.

The home has an effective complaints process which people are aware of. Most complaints are dealt with informally by the registered manager. CQC recieved a complaint in March 2013 and passed the infromation onto the provider. We saw that this complaint had been appropriately responded to.