The Old Vicarage

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe and received safe care which met their needs. The provider had an up to date safeguarding policy and procedures in place. Staff had completed safeguarding training which was refreshed periodically. When questioned, staff knew how to identify abuse and how to escalate concerns. The provider used a log to document any safeguarding concerns, albeit this did not detail outcomes and lessons learned. This information was documented elsewhere; however, we discussed with the provider the benefit of it also being included on the log for ease of reference, which they agreed to do moving forwards.

Deprivation of Liberty Safeguards (DoLS) are an important part of the Mental Capacity Act 2005. They involve providers seeking legal authorisation from the local authority where they need to deprive people who lack capacity of their liberty. For example, preventing them from leaving the care home without support, or having keypads on internal doors which prevents free movement. DoLS aim to ensure that such deprivation of liberty only happens when it is necessary, proportionate and in the person’s best interests. DoLS applications had been submitted as and when required, with a log used to monitor applications, their outcome and when any reapplications were due.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider completed a range of risk assessments regarding the environment, equipment and any related risks to people and staff. These included risks related to trips and falls, access to exits, internal doors and staircases, and the use of Dorgards, which are devices which allow doors to be kept open to support freedom of movement, but automatically close the door when the fire alarm is triggered.

The provider had installed a new alarm system onto all internal access doors, including those leading to staircases, which triggered if the door was not closed properly. Signage was also in place reminding staff and visitors to ensure they closed doors fully behind them.

A fire risk assessment had been completed by an externally accredited company in June 2024. Although some issues had been identified, we noted remedial works had been completed timely, to ensure compliance with fire regulations. Evacuation guidance was in place, and regular fire drills had taken place, to ensure staff knew how to support people safely and effectively in an emergency.

Required checks of premises and equipment had been completed in line with guidance, for examples fire alarm call points, hoists, slings, gas and electrical appliances.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People, relatives and staff told us enough staff were deployed to meet needs, our observations supported this. The provider used a system for ensuring staffing was in line with people’s dependency level and assessed need. Rotas were compiled using this information. We found staff had been recruited safely, with all necessary employment checks completed.

Staff shortages, such as through sickness or annual leave, were initially covered by existing staff. However, when necessary, the provider utilised agency staff. We noted the same agency, and staff were used to help with continuity of care. The provider had ensured any agency staff had been recruited safely and were up to date with any training considered mandatory.

Newly recruited staff were required to complete a thorough induction, and if new to working in care, the Care Certificate. This is a set of 16 standards for the health and social care support workforce in the UK, developed by Skills for Care, Skills for Health, and NHS England to ensure new workers have the necessary skills, knowledge, and behaviours to provide safe, compassionate, and high-quality care. New staff were also required to complete a 6-month probation period, before their position was made permanent.

Staff completed a range of training courses relevant to their role and the needs of people they supported. A matrix was used to monitor completion. This showed the vast majority of staff were fully up to date, with any missing sessions scheduled to be completed in the near future.

Staff had received supervision and appraisals in line with the provider’s policy. A separate matrix was used to document these and monitor compliance. These meetings provided the opportunity to discuss staff performance, address any issues and discuss career pathways.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.