The Old Vicarage Care Home

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 requires improvement. At this assessment the rating has remained requires improvement.

The service was in breach of legal regulations in relation to safe care and treatment and staffing.

This service scored 50 (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 proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. However, some improvements were needed where people may be at risk of harm when eating. Lessons were learnt to continually identify and embed good practice. Any incidents about people's safety were discussed with staff in a timely way, with action taken to mitigate further risks. A relative commented, “[Name] is looked after, they had falls early on but not recently, staff keep an eye on [Name].”

Staff at the service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services. People’s pre-admission assessments were completed prior to people moving into the service, to ensure staff understood people’s health and care needs, and any associated risks. A person commented, “All the information came from the other home.” A hospital passport was prepared to ensure people’s needs could be met, if they moved elsewhere. A person told us, “There is a pack with everything in it, it goes with you in the ambulance.”

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.People and relatives told us they felt safe, they would speak with staff if they were worried, and they always felt listened to. Their comments included, “I am safe. I have a key for my room”, “I trust the staff” and “‘I have settled, I am safe. Staff do everything for me.”

The provider did not work well with people to understand and manage risks by thinking holistically. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.Improvements were needed around managing risks and ensuring identified need was transferred to a care plan. Then this detailed how a person wanted and needed to be supported to ensure their safety, and that person-centred care was provided. Risk assessments and corresponding care plans were not all robust or person-centred. Where people experienced agitation and distress, care plans did not include guidance for staff about triggers and de-escalation techniques for staff to use to help re-assure the person. Moving and handling risk assessments did not accurately reflect identified risks to people. A person whose nutritional care plan stated they were at risk of choking and needed to be observed at mealtimes, was not supervised whilst eating their lunch time meal. Appropriate equipment was available if people needed assistance. A person told us, “I have the hoist to use in the bathroom.” A relative commented, “[Name] has as sensor mat in their bedroom, as they can fall, and this alerts staff.”

Staff at the service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, we observed a seat for a bath aid in a middle bathroom was corroded and showing signs of wear and tear, which could compromise the safety of a person. The manager told us that this would be addressed. Despite this, other equipment was regularly serviced to maintain safety.

The provider did not ensure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. There were insufficient staff to support people safely. 2 members of staff were available on each floor of the home, this included the senior carer whose role was not only direct care giving, but they were also responsible for administering medicines, dealing with professionals and relatives. This meant when they were busy only 1 staff member was available. Some people needed 2 staff members for moving and assisting support and 1-1 support for eating and personal care. Improvements were needed to staffing levels and staff deployment, so people received safe, timely and person-centred care. The manager had introduced an additional staff member to work across both floors. However, on both floors of the home people sat unoccupied during large parts of the day. As described in the risk section of the report, it was observed a person who required supervision when eating, due to the risk of choking, was left unsupervised during their lunchtime meal, in the lounge on the middle floor.

Staffing rosters and staff feedback showed ancillary staff were not employed in sufficient numbers, as only 1 member of domestic staff was on duty, to cover the building at weekends and some weekdays. We were informed after the inspection that this was being addressed.

Staff did not always receive training appropriate and relevant to their role, or have their competencies assessed in line with the provider’s own policies or current best practice guidance. The provider’s training matrix showed not all staff had received training relevant to meet the needs of people they supported. We received information after the inspection about some planned training. A staff member commented, “There are a few courses in the next couple of months.” However, the planned training did not include dementia care training or the required learning disability training which is now mandatory training for all staff.

Improvements were needed to staff recruitment to ensure all staff were appropriately recruited. A staff file viewed did not show all the necessary checks to show a person’s fitness to work. There was not a right to work check completed, sufficient checks and references had not been sought to verify a person’s fitness to work.

The provider did not always assess or manage the risk of infection effectively. They did not always detect and control the risk of it spreading. People were not always protected from the risk of infection because premises and equipment were not kept clean and hygienic. There was an unpleasant odour in parts of the home. Some surfaces and chairs were sticky. There were areas of the home where paint was chipped, walls were marked, making surfaces harder to clean and impacting good infection prevention and control.Staff told us personal protective equipment (PPE) and all cleaning materials needed were available. They confirmed they had received infection control training.

The provider did not always make made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened to people’s medicines. There was information available on how people took their medicines. A person commented, “I get tablets every morning, regular, I never go without.” However, some people were prescribed medicines to be taken on a ‘when required’ basis. Guidance for how these medicines should be administered was not person-centred. The staff training matrix did not show that staff responsible for administering medicines had received up to date medicine training, or had their competencies reassessed. We were informed by the manager after the inspection, staff competencies had just been reassessed and face to face medicine training was planned.