The Old Vicarage

The Old Vicarage is a residential care home which provides accommodation and personal care for young adults whom are living with a learning disability and/or autism. At the time of our inspection 13 people were living there. The service can support up to 14 people. The service is split into two units known as ‘The Old Vicarage’ and ‘The New Vicarage’.

The Old Vicarage consists of four bedrooms in the main house and three apartments on the first floor. The New Vicarage consists of five apartments and a two-bedroom cottage. Each apartment is self-contained with bedrooms, bathroom facilities and living space. Each area has their own entrances with dedicated staff teams, communal space, garden space and separate offices for managers.

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

People were not always kept safe from the risk of abuse. There were times when people had been left without the support they needed, placing them at risk of harm. Most relatives felt their family members received safe care and support generally. However, some relatives expressed concerns about the frequent changes of management which led to inconsistencies in how risks to people were managed. There were enough staff, but at times, they had not always been deployed effectively. The provider had taken action to ensure people were not left without the support they needed.

People did not consistently receive their prescribed medicines safely. Accidents and incidents were not consistently monitored to identify trends and to prevent reoccurrences. This meant that the opportunity to learn lessons and reduce the risk of future incidents did not always happen.

The service was not consistently well-led. Frequent changes in managers since the last inspection in 2019 had resulted in a lack of robust oversight of the quality of care. The provider worked with the local authority to investigate any incidents or accidents. However, lessons learnt from investigations were not consistently acted on to improve care for people.

Staff understood how to recognise and report concerns or abuse. Risks associated with the service environment were assessed and mitigated. There were clear plans in place to guide staff in what to do in an emergency, and staff knew what the plans were. Relatives and staff felt there were enough staff available to meet people’s needs and provide 1-1 support when this was needed.

The service was clean and staff knew how to reduce the risk of acquired infections. We saw some staff did not always wear their personal protective equipment (PPE) correctly. The provider addressed this on the day of our inspection.

The provider had recently appointed two new managers at the service, and relatives and staff told us about the positive impact this had.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. This was due to the number of avoidable incidents that happened at the service, leading to people being put at risk. The provider was working to address the concerns we found to ensure people felt safe and care was person-centred.

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

Rating at last inspection

The last rating for this service was Good (published on 14 May 2019).

Why we inspected

We received concerns in relation to unsafe staffing levels and medicines management. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 coronavirus and other infection outbreaks effectively.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. The provider has already started work on improving the quality of care in response to the concerns we found. Please see the Safe and Well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Old Vicarage on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service:

The outcomes for people using the service reflected the principles and values of Registering the Right Support. People were supported by staff to exercise choice in how they lived their lives. Independence and inclusion were important aspects of people's lives as they participated in home and leisure opportunities.

Staff understood their responsibility with keeping people safe. Staff assessed, managed and regularly reviewed risks to people’s health and wellbeing. Care plans detailed how to manage behaviours that challenge in a positive way that protected people’s dignity and rights. Staff recorded accidents and incidents appropriately. There were enough staff to ensure that people's needs were met safely. People received their medicines as prescribed and there were good infection prevention and control practices in place.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. They ensured that people were supported to maintain good health and nutrition. The environment was adapted to meet people’s needs. People were supported by staff who had relevant training, skills and experience to care for them. Staff worked with other health and social care professionals to achieve good outcomes for people’s health and wellbeing.

Staff had meaningful relationships with people and shared interests. We received many positive comments from people, relatives and health and social care staff. Staff respected people’s privacy and dignity.

People had personalised support plans which were regularly reviewed. People’s support plans included information about their wishes and incorporated information about empowering people to be independent. People were supported to live full and active lives. Staff identified people’s information and communication needs and provided this support so people had a voice. Complaints were appropriately followed-up by the provider.

There was a strong and positive focus on continuous learning and improvement. Regular audits took place to measure the success of the service and to continue to develop it. People, staff and the registered manager described a culture which focussed on people and ensuring they received good care. Staff worked well with other health and social care professionals to support people. The providers rating was displayed on their website and within the home. We had received notifications of events and incidents and this enabled us to reflect on the action the provider is taking to ensure people’s ongoing safety.

More information is in the full report below.

Rating at last inspection: Rated as requires improvement, report published 19 June 2018.

Why we inspected: This was a scheduled inspection based on the rating at the last inspection.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

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

At our previous inspection on 29 September and 2 October 2017, we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for Regulations 9, 12, 13, 17 and 18 relating to person-centred care, safe care and treatment, protection from abuse and improper treatment, governance and staffing. This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures. Some improvements were still required and we found a continuing breach of regulation 17.

The Old Vicarage is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The Old Vicarage accommodates up to 14 people in two adapted buildings; 12 people live in the main house and flats within the main house, two people live in a separate building called The Cottage. At the time of our inspection 14 people lived at The Old Vicarage.

The service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The service is required to have a registered manager. 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 time of our inspection there was a registered manager in post and was present at the inspection.

The premises had not always been safe. We made a recommendation about the health and safety management of the premises.

Improvements were needed to how medicines were managed and how medicines administration records were made.

Improvements were needed to help prevent and control risks from infection.

Audits and checks had not always effectively identified and responded to risks, and effectively assessed and monitored the service.

Processes were in place to ensure risks and people’s health needs were assessed, managed, monitored and responded to. People were supported with a 'positive behaviour support' model of care that helped to reduce the number of incidents of behaviour that challenged. People's care was based on a least restrictive approach.

People’s needs and choices were promoted in a way that prevented and reduced the impact of any discrimination. People’s communication needs were assessed and people were supported to communicate effectively with staff. The Accessible Information Standard was being met. The principles of the MCA were also followed.

Enough staff were available to meet people’s needs as well as spend time with people on an individual basis. Staff had been trained in appropriate safeguarding procedures and understood how to raise any concerns. Recruitment processes were in place to ensure any new staff would be subject to pre-employment checks on whether they were suitable to work at the service.

Staff were trained and supported. Staff were caring and understood subtle changes in people's moods and responded in reassuring ways.

People’s privacy was respected and they were supported to be active in their local communities as well as within the home. People enjoyed a variety of different interests and activities both in their home and in the community.

People were supported to be independent and were involved in decisions about their care.

The premises had been adapted in ways to make sure it was suitable for people using the service.

People were given opportunities to raise any issues or concerns; there was a complaints process in place to manage and respond to any complaints should they be made.

The service focussed on providing care that was centred on individuals; the management team promoted an open and transparent management style.

At this inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

The service is registered to accommodate up to 14 people, and there were 14 people living there when we visited. The service has two separate buildings. The main house has five people living there. Within the main house there are also four separate flats. One flat has three people, two flats have one person in each, and the fourth flat has two people. The Cottage is a separate building with two people living there. All the people living at The Old Vicarage are younger adults who have diagnoses of moderate to severe learning disabilities and other complex healthcare needs, who require an appropriately specialised service of residential care.

We previously carried out a comprehensive inspection of the service in February 2017, when The Old Vicarage was rated as Good. Before the inspection we received two notifications from the provider about allegations of abuse. One of the allegations is still subject to investigation by the local authority and the police. As a result this inspection did not examine the circumstances of this incident. In addition, whistle-blowers provided information of concern about the quality of care provided. The concerns related to the use of physical restraint, staff training, staffing levels, and potential lack of choices for people.

The service had a registered manager. 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. The registered manager was present on the first day of the inspection visit. The provider's nominated individual was present on the second day of the inspection visit.

People were not kept safe from the risks of avoidable harm and abuse. People were at risk of harm because risks associated with physical restraint were not identified and mitigated. Risks associated with the environment were not reduced and mitigated.

People were not kept safe from risks arising from their health conditions. Action was not always taken to monitor and respond to changes in people’s health needs. People were at risk of harm because risks associated with their health needs were not identified and mitigated. Medicines were not managed safely.

People were at risk of being physically restrained when this was not proportionate or in their best interests. There were no effective safeguards in place to ensure physical interventions used were minimal and reasonable. Consent to care was not always sought in accordance with legislation and guidance, and people were at risk of care that was overly restrictive and unlawful.

Staffing levels were not consistently sufficient to ensure people received the care and support they were assessed as needing. People received care from staff who did not have the skills or training to support them effectively. People were at risk of harm because staff did not have training to help them to understand how to effectively support people’s health and care needs.

Staff spoke in a caring way about the people they supported, but this was not consistently reflected in some of the staff’s actions or language. People were not consistently supported to participate in designing or reviewing their care.

People were at risk of having care that was not tailored to meet their needs, preferences and aspirations. People did not always receive support to take part in activities within the home and in their community. People were not always supported to communicate effectively.

The service was not managed well. There were failures to meet the fundamental standards in relation to safe care practices, insufficient staffing levels and staff training, planning and delivery of people’s care, and following relevant legislation. Quality assurance processes to ensure people’s safe care were not effective.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC's regulatory response to these concerns found during inspection is added to reports after any representations and appeals have been concluded.

We found one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Old Vicarage is registered to accommodate up to 14 people and specialises in providing care and support for people who live with a learning disability. At the time of the inspection there were 14 people using the service.

On the day of our inspection there was a registered manager in place. 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 were safe living at the service because staff knew how to recognise and report any incidents of harm. Staff were confident that the registered manager would deal with any concerns that they reported. Systems were in place for staff to identify and manage risks and respond to accidents and incidents. Staffing levels were adequate to meet people’s needs. Staff were recruited through safe recruitment practices. Medicines were safely administered and stored.

Some staff did not receive specialist training to provide effective care. Some staff did not receive supervision at the frequency the provider expected. The manager applied the principles of the Mental Capacity Act 2005 (MCA) and Deprivations of Liberty Safeguards (DoLS), so that people’s rights were protected. People were asked for their consent before care and support was provided and this was respected. People received sufficient to eat and drink and their nutritional needs were catered for. People’s healthcare needs had been assessed and were regularly monitored. The service worked well with visiting healthcare professionals to ensure they provided effective care and support.

Staff were kind, caring and respectful towards the people they supported. Staff were aware of people's support needs and their personal preferences. Information was not available for some people about how to access and receive support from an independent advocate. People and/or their relatives were involved in the development and review of their support plans. People's independence privacy and dignity were promoted and respected by staff.

People received care and support that was personalised and responsive to their individual needs. Regular reviews of people's care and support needs took place. People were supported to participate in activities, interests and hobbies of their choice. The complaints policy was accessible for everyone.

Staff understood the values and vision of the service and had a clear understanding of their roles and responsibilities. People and their relatives were not given opportunities to complete surveys about the service however, they had other opportunities to be involved in the development of the service. There were systems in place to monitor and improve the quality of the service provided.

We carried out an unannounced inspection of the service on 28 and 29 January 2016. The Old Vicarage is registered to accommodate up to 14 people and specialises in providing care and support for people who live with a learning disability. At the time of the inspection there were 13 people using the service.

On the day of our inspection there were two registered managers in place, however one of them was not currently working in this role. 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.

During this inspection we identified concerns that people were not protected from the risks associated with financial abuse. This was because robust processes to monitor the way people’s money was spent and then recorded were not in place.

The risk to people’s safety was reduced because staff had attended safeguarding adults training and knew the procedure for reporting concerns if they thought people’s safety was at risk. Risk assessments had been completed in areas where people’s safety could be at risk; however these had not always been reviewed within the required timeframe as recorded in people’s support records. Staff were recruited in a safe way and there were enough staff to meet people’s needs and to keep them safe.

Accidents and incidents were investigated. Assessments of the risks associated with the environment which people lived were carried out. People had personal emergency evacuation plans (PEEPs) in place. People’s medicines were stored, managed and administered safely.

People were supported by staff who received an induction, were well trained and received regular assessments of their work.

The registered manager ensured the principles of the Mental Capacity Act (2005) had been applied when decisions had been made for people. However they did not always record how decisions had been made in people’s best interest. People told us they were free to do as they wanted and to go where they wanted. Deprivation of Liberty Safeguards had been applied for where needed.

There was a clear aim to reduce the use of restraint within the home, however at the time of the inspection; an investigation was in place due to the allegation that staff had used restraint inappropriately.

People spoke highly of the food and were supported to follow a healthy and balanced diet. People’s day to day health needs were met by the staff and external professionals. Referrals to relevant health services were made where needed.

Staff supported people in a kind, caring and respectful way. People were treated with dignity and staff listened to and acted upon their views. Staff responded quickly to people who had become distressed. Staff used a variety of techniques that enabled them to communicate effectively with people.

Processes were in place that enabled people and their relatives to contribute to decisions about their care and support needs. Independent advocates were used to support people with decisions about their care if they did not have relatives to do so. People’s friends and relatives were able to visit whenever they wanted to.

People’s support records were in the process of being developed to ensure they were person centred and focused on what they wanted. The current support records contained details of the people’s personal preferences and how they would like to be supported with their personal care. Care records were reviewed, although a small number of support plans had not been reviewed as regularly as others. Staff knew people’s personal preferences and what interested them. People were encouraged to take part in activities that were important to them. People and relatives felt able to raise a complaint and thought it would be acted on appropriately.

There were a number of quality assurance processes in place that regularly assessed the quality and effectiveness of the support provided. However, these had not identified the concerns raised within this report.

People who used the service were encouraged to provide their feedback on how to improve the quality of the service they received. Staff understood what was expected of them and felt able to contribute to the development of the service. People spoke highly of the registered manager. The registered manager understood their responsibilities. Staff understood the aims and values of the service and could explain how they used them in their roles.

We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the provider to take at the back of this report.

On 24 April 2014, we conducted an inspection to check whether improvements had been made. In addition to this, we also checked whether the provider was compliant in two other areas; respecting and involving people who used services and care and welfare of people who use services.

Due to the complex needs of the people who used the service we used a variety of other methods to establish whether the provider was compliant. This included speaking with the owner, manager, management consultant, activities coordinator/support worker, supervisor and a support worker. We spoke with three relatives, observed staff interactions with people and reviewed records relevant to the running of the service. We also carried out a tour of the building and observed activities taking place.

This is a summary of what we found '

Is the service safe?

People who used the service, or their relatives where appropriate, were involved in decisions relating to their care. Care plans were well written and contained detailed information, which informed staff how they should provide care and support that kept people safe.

People received care and support in an environment that was safe. Each person had a personal emergency evacuation plan that was written appropriate to their needs. We saw staff interact with people in a calm, friendly and caring way. People who used the service appeared happy throughout the inspection.

There were procedures in place to identify and prevent abuse to people occurring. Staff knowledge of the referral procedures had improved since the last inspection. They could now explain who they should contact, both internally and externally, should they suspect someone had been the victim of abuse.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We saw proper policies and procedures were in place. The manager could explain the procedure for submitting an application. Staff had received training in this area and we saw they were booked to attend a refresher training course in June 2014.

A relative of a person we spoke with told us, 'I have no causes for concern, I know my son is safe there.'

Is the service effective?

Staff spoken with had a good knowledge of people's needs. We looked at staff personnel records which contained sufficient information that showed they had the skills and experience needed to support people living in the home.

We saw improvements had been made since the last inspection with regular assessment of staff performance now carried out and recorded.

Staff told us they felt supported in their role and had received the appropriate training to carry out their role effectively.

A relative we spoke with told us, 'Staff go out of their way, they take my son to football, cricket, trips to London. I would recommend this place to anyone.'

Is the service caring?

We observed staff interacting with people. All staff were encouraging, supportive and caring. People were encouraged to take part in activities or enabled to make their own decisions about what they wanted to do. There was a relaxed and calm atmosphere throughout the home. Staff smiled and talked to people with respect. When people required privacy this was respected.

Whilst we could not speak directly with the people who used the service during the inspection, it was evident from observing their interactions with staff they enjoyed and felt at ease in their company.

Is the service responsive?

People's needs had been assessed before they moved into the home. The registered manager told us if someone new to the service required a specific area of support then they would ensure that staff received the appropriate training for this. We saw staff had received training on how to support a people if they had an epileptic seizure.

We looked at records which confirmed that people's interests, beliefs and needs had been recorded and identified and staff responded positively to these.

Is the service well-led?

Since the previous inspection a new manager had been appointed. They have introduced a number of systems to monitor the quality of service provided for people. This included care plan reviews, environmental checks and finance audits. They told us they also planned to carry out a 'resident and relative survey' very soon to obtain people's views on the service and to help shape continued improvement.

Staff spoken with were aware of their roles and responsibilities and support plan records showed what people were to be consulted when decisions about a person's care were being discussed.

We saw investment had taken place on the d'cor of the home such as a newly decorated reception area for visitors, an extension to the main building with fully renovated, en-suite bedrooms and new furniture throughout the building.

Staff and relatives of people who used the service spoke positively about the manager. A support worker told us, 'The manager is incredible, best I've worked for.'

It was clear that significant improvements had been made since the previous inspection in October 2013.

People were consulted before decisions about their or their family member's care were made. A relative we spoke with told us, 'They (staff) always involve me a lot, there is an informal approach, but I have a really good opportunity to discuss things.'

Care was planned and delivered to meet people's needs and ensure their safety. A relative told us, 'I know they (family member) are safe; there are always staff around. They (staff) know how to work with my family member; they have a very encouraging approach.'

People were not always protected from the risk of abuse. Processes were in place to protect people but staff were not always aware of the individual requirements relating to each person nor who to report allegations of abuse to externally.

Staff were not always supported in their role. Staff were well trained however supervisions and appraisals of their performance had not always been carried out.

There were not effective systems in place to assess the quality of the service that people received.