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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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.

The registered manager told us they took opportunities to learn and improve the service to people whenever possible. Staff were supportive of this approach and told us they felt the service had made improvements. They understood there were on-going plans to make further improvements and were looking forward to contributing to these.

People felt involved in their home and told us they were happy living there. One person said, “I feel really happy here because the staff are not just staff, they are like my family. Everyone is lovely. It is like one big family.” Staff spoke warmly about the people they cared for, and we observed caring and person-centred interactions throughout our inspection.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff felt their leaders were approachable and treated them fairly. The registered manager was supported by other leaders including a deputy manager and the home’s nursing staff. A registered manager from another of the provider’s care homes provided support and additional quality assurance checks. These leaders were well known to staff who told us they were all helpful and supportive. One staff member told us, “The registered manager is really approachable,” another staff member described the registered manager as, “Firm but fair.”

Staff felt leaders were caring. One staff member told us, “As staff we are happy and looked after as well.” Minutes of staff meetings showed staff were thanked for their contributions to improvements and the positive morale in the staff team was recognised and valued.

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

Staff consistently told us they could raise any concerns with their leaders and actions would be taken to make improvements. One staff member told us, “You can discuss anything with the Registered Manager,” another staff member said, “It feels okay to raise concerns.” This helped demonstrate leaders had created a culture where any concerns would be listened 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.

Staff completed training in equality, diversity and inclusion and told us they felt treated fairly. Staff told us they could contribute their views and enjoyed working at the service. One staff member said, “It’s a nice atmosphere here at the moment and I like working here.” Leaders had created a positive culture where staff felt included and treated fairly.

Some further improvements were required to help ensure the provider had clear responsibilities, roles, systems of accountability for good governance. Information about risk, performance and outcomes, needed to be clearer to ensure effective governance.

Care plan and risk assessment records had improved since our last inspection. However, there were some further improvements needed in other records such as some monitoring charts and some medicines administration records. Policies and procedures were in place however not all of these were in line with current guidance. The registered manager told us they would take action to make these improvements.

The registered manager reviewed and maintained an oversight of incidents, accidents and safeguarding events. Whilst this identified lessons learnt and actions taken these sometimes appeared generic and it was not always clear which individual incidents had led to specific actions or trends being identified. Similarly, we found reviews and decisions as to whether an incident required a safeguarding referral to be made had not always been recorded. Wediscussed this with the registered manager who agreed to review how they recorded their oversight audits.

Audits and checks maintained an overview on areas such as infection prevention and control and health and safety in the environment. This helped risks to be identified and actions taken to help reduce risks when possible.

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.

Staff worked with a range of other health and social care professionals such as speech and language therapists, dieticians, social workers and local authority and health care commissioners. Working in partnership with these other professionals helped to achieve positive outcomes for people.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Since our last inspection, the provider had followed an action plan and had achieved improvements to the environment, people’s care and care records. This demonstrated the provider was focussed on improvement and learning. The provider’s action plan had identified further ongoing actions to other areas of the environment and facilities to help ensure a continuous commitment to improvement.