The Old Vicarage

Registration details

The location ID for The Old Vicarage is 1-125882171.

CQC register The Old Vicarage to carry out these legally regulated activities. Contact us if you think The Old Vicarage is operating services not listed here.

Type of service

• Residential homes

Service specialism

• Caring for adults over 65 yrs
• Dementia

Local authority

Norfolk

Monitored services

CQC register The Old Vicarage to carry out the following legally regulated services here:

Accommodation for persons who require nursing or personal care

Mrs Beatrice Emma Kelly is responsible for these services.

Condition of this registration relating to carrying out this regulated activity

The registered provider must not admit any service user to the location at The Old Vicarage, Norwich Road, Ludham, Great Yarmouth, Norfolk NR29 5QA without the prior written agreement of the Care Quality Commission. This includes service users who require respite care. The term ‘admit’ includes readmission of any service user.

By 10am on Friday 09 February 2024, and for each first Monday of every month thereafter, the registered provider must carry out a full review of all staff recruitment checks, ensuring that all staff including any newly employed staff have a suitable induction, training package, and Disclosure and Barring Service (DBS) outcome prior to working with service users alone. The registered provider must supply the Care Quality Commission with a report detailing the recruitment checks in place for each staff member. The registered provider must supply the Care Quality Commission with details of any actions taken in response to identified shortfalls within the report.

By 10am on Friday 09 February 2024, the registered provider must ensure that all staff are suitably competent and trained to assess, plan, and manage risks including the administration/management of medicines and behaviours that are associated with dementia for the role they are to undertake. Evidence of this training and competency checks must be submitted to the Care Quality Commission within five days of the date of this notice together with an action plan setting out any further training required and the timescale for this. The registered provider must provide a report to the Care Quality Commission following such review on every first Monday of every month.

By 10am on Friday 09 February 2024, and for each first Monday of every month thereafter, the registered provider must ensure sufficient levels of staff are always deployed to meet the needs of service users in a safe and personalised manner. The registered provider must provide written confirmation to the Care Quality Commission that staffing levels have been reviewed, met, and amended to meet service user’s dependency and care needs as required. The registered provider must supply the Care Quality Commission with details of any actions taken in response to identified shortfalls. The registered provider must supply the Care Quality Commission with staff rotas to demonstrate that each shift has been staffed as assessed.

The registered provider must ensure that all service user’s care needs are reviewed immediately, and a copy of this review be sent to the Commission by 10am on Friday 09 February 2024, and each first Monday of every month thereafter, identifying any shortfalls and the actions taken in response. The review must:
a. Identify immediate risks associated with service user’s care needs and inform an urgent review and updating of care plans and risk assessments. These need to include, but not be limited to, risks in relation to living with dementia, constipation, and falls.
b. Ensure escalation to appropriate medical professionals takes place as necessary which should include utilising specialist advice from a multidisciplinary professional team to assess and mitigate the risks relating to behaviours that are associated with people living with dementia and other health conditions.
c. Identify where care plans, risk assessments and health monitoring assessments are missing for medical conditions and put these in place immediately.
d. Ensure service users have personalised care plans and risk assessments in place detailing what support staff need to provide to meet their individualised needs and risks, including in the event of a fire requiring evacuation.
e. Include a full review of all service user’s medicines and associated allergies. The registered provider must supply the Care Quality Commission with a copy of this review, detailing its findings and any actions taken to address identified shortfalls.

The registered provider must ensure effective quality assurance processes are established and implemented to improve the way you assess, monitor, and improve the quality of the service and protect service users from the risk of harm. Evidence of your quality assurance framework must be submitted to the Care Quality Commission within five days of the date of this notice. Thereafter, the registered provider must send a report to the Care Quality Commission on the first Monday of each month with details of completed quality monitoring audits and checks. This must include areas covered, your findings and any responsive actions, clearly identifying who is responsible and the timescales for this.

Terms of this registration relating to carrying out this regulated activity

The Registered Provider must only accommodate a maximum of 41 service users at The Old Vicarage.

The Registered Provider must not provide nursing care under accommodation for persons who require nursing or personal care at The Old Vicarage.