The Vicarage Residential Care Home

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 requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance and oversight as we found processes and procedures were not effective as they did not identify issues and concerns, we found during this assessment.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

There were policies and procedures in place to support vision, strategy and culture within the organisation. However, these had not always been effective. There was no evidence of how leaders shared their organisational strategy with people and staff.

The registered manager was not always visible within the service as they were mostly based in the office located off the main premises which impacted on their level of an oversight. Staff and people spoken positively about the registered manager and raised no concerns. One staff member told us, “I can always speak to the manager, and I feel they care about us staff.” People told us the registered manager was approachable and they could always speak to them when needed.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leader did not always demonstrate they had the skills, experience and credibility to lead effectively.

Leaders did not always understand the priorities within the service and were not always responsive in identifying issues and concerns impacting on people’s safety and their outcomes. For example, the fire safety concerns and health and safety issues mentioned earlier in this report. There was no evidence of effective provider’s oversight in place.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

There were policies and procedures in place to support freedom to speak up.

People, their relatives and staff felt they could speak up and raise concerns they had. The provider encouraged people and their relatives to share their feedback. However, there was no evidence how this feedback was used to improve people’s outcomes and overall care delivery.

There were regular care reviews undertaken to ensure care was meeting people’s needs and people had an opportunity to discuss their wishes. The provider had a complaints and comments policy in place. We saw evidence complaints were addressed. However, there was no evidence of how learnings were identified and used to improve care outcomes for people.

Staff surveys were sent out and feedback from them discussed with staff in meetings.

The results were positive, and we saw that staff were encouraged to discuss any issues or ideas in their supervisions. Staff told us that any concerns raised by them were dealt with effectively by management.

The registered manager told us, they operated an open door policy and staff and people could speak to them at any time.

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.

The provider adhered to The Equality and Diversity Act. There was a diverse workforce in place, and the provider recognised values of diversity and equality within the organisation. However, there was very little evidence of how staff were recognised for the work they did. Staff told us they felt supported by the registered manager. One staff member told us, “When we need support, they do support us.”

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

There were clear responsibilities, roles and governance systems within the organisation. However not all of these systems were effective.

During our assessment we found that some of the duties of the registered manager were not always carried out. For example, we were not notified about the registered manager’s absence which was longer than 28 days or when people had falls.

The oversight that was in place was not always effective as some areas identified during this assessment were not followed up or acted upon regarding health and safety and fire safety.

There was a lack of effective provider’s oversight in place, and we noted some concerns raised in our previous inspections were not resolved and no improvements were made.

For example, in relation of the lack of person-centred care and delivery of meaningful activities for people. We were not assured care for people was designed to meet their individual needs and preferences.

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.

The provider overall worked and collaborated well with stakeholders and partners to ensure people’s outcomes were met. For example, people had access to weekly visits from the GP and district nurses visited regularly. One person told us, “The doctor comes in each week and if needed a dentist they would call one, I’m sure.” One relative told us, “They are really on the ball if my loved needs anything, and they bring the doctor straight away.” People also received support from the OT and physio.

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 failed to address some of the concerns and areas for improvement identified during our previous assessments around person centred care and meaningful activities and social engagement. One person told us, “I am a smoker, but I can’t get out to have one as I have to ask for someone to take me out and they[staff] are always busy. I like to get out and not feel so closed in here.” Another person told us, “It’s dead boring here, nothing to do. Have to wait for people[staff] to do things.”

There was a number of audits and checks in place completed regularly. However, we found these to be ineffective as they did not pick up the issues and concerns, we found during this assessment. For example, maintenance checks had not identified issues we found in some people’s bedrooms such as damage to the walls or faulty equipment.