The Old Vicarage

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

During this part of the assessment, we found 2 breaches of the legal regulations, these were, staffing and safe care and treatment. Risks around falls had not been appropriately identified and assessed. Care plans were not personalised and contained contradictory information in relation to other records. Pre-employment checks had not been completed, we had concerns around night staff not receiving full training to be able to safely support the people using the service. There had been some improvements made to our concerns around safety within the environment from the last inspection however when inspecting external areas of the building, we found bins were overflowing and left unsecure with no locks. Medicines were not managed safely, service users had not received medication that was prescribed. There was poor risk management.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were asked if they felt safe living in the service, one person said “Yes, but some staff can’t take the top off a beaker or put a straw in the top. That’s basic stuff so it’s worrying that they could be dealing with riskier stuff.”

Staff were aware of the procedures in the event of accidents and incidents, one staff member said “I would inform management and if it was serious I would contact 111 or 999. However, there was not a protocol in place for staff to follow regarding falls.

Records of accidents and incidents were not always completed as a full process from start to finish, there was no evidence of actions from management or the providers to mitigate future risk. Two people using the service had a physical altercation with no staff present resulting in significant injuries to both, a similar incident had occurred a few days before this with the same people and staff intervened. Peoples risk assessments and care plans had not been reviewed after the first incident therefore people were put at an increased risk harm as no measures had been put in place.

People were not involved in the planning of their care, therefore engagement with external professionals and services was minimal unless staff arranged visits. One person said “I did ask about my glasses a few weeks ago. I need new glasses and they said they’d sort it out, but I haven’t heard anything.”

Staff were aware of how to make contact with external professionals and services but they were unable to tell us about individuals pathways and how people were being supported with this.

Health care professionals who visited the home told us “referrals come through when they notice concerns with patients in a timely manner”, another healthcare professional said “All staff I have encountered were respectful and kind to me and the resident during this visit”.

Care plans we reviewed were not personalised, therefore they were unable to provide specific details about care pathways or transitions. Falls referrals were not being followed up appropriately. This increased the risk to people experiencing falls.

People told us they felt safe in their surroundings, however, we observed incidents of safety not being adhered to.

Staff had an understanding on how to report safeguarding concerns, staff had received safeguarding people from abuse training online. However staff did not follow the procedure of staff being based in the communal lounge, therefore an incident happened that may have been prevented and people would have been safeguarded.

Risks in relation to peoples bowels and fluid intake had not been sufficiently monitored or identified. We reviewed a bowel chart record for one person who had not opened their bowels for 14 days, staff requested GP intervention on day 6. The GP prescribed medication, however, staff did not administer the prescribed dose. Fluid chart records were also reviewed, out of 15 people only 2 people met their average fluid intake this was assessed over a 22 day period. No records showed actions how staff are to respond to fluid levels not being reached.

There was no evidence of people or their families being supported to be involved in their care planning or managing their own risks.

Staff did not have a clear understanding of peoples needs or risks, for example we spoke with two staff members on a site visit that gave contradicting information about how frequently a person should be checked for a welfare check.

Risks to people were not assessed or managed safely. We observed a lunchtime meal where a resident with mobility restrictions was not supported to eat their food in a safe way.

Risk assessments were not person centred and found to be generic. They were not assessed appropriately to people’s individual needs and risks. People were not considered to be involved in managing their own risks.

One person said “The room is always kept tidy and clean, though there’s only me most of the time and I don’t make much mess.”

Staff said they felt the environment was safe and clean.

Improvements had been made to the environment since the last inspection, some unused rooms were locked and there was more signage in the service however there was limited offers for people living with Dementia and maintenance logs had not been fully completed or current. The external environment had not been assessed for risks, we found bins overflowing with no locks, bitumen paint next to one of the oil tanks and a laundry service being stored in an outdoor plastic storage shed where the lid was not secured.

The Fire risk assessment had been reviewed in October 2023 identified that not all staff had received training in using the fire evacuation mat. The training had not been completed at the time of the assessment. The quality assurance system in place was ineffective at assessing, monitoring and mitigating risks to health, safety and welfare of the people living at the service.

One person said “I usually wake before the staff come. I use my bell. The latest thing is after 2½ minutes the bell sound changes and becomes an emergency call. The issue is this. The staff will come in here (room) and turn the bell off. They then say - I’ll be back, or I’ll be back soon. No indication of time. So, after 15 minutes I ring my bell again. If I knew when to expect them back it would be much better but as I don’t I call them again which I think is reasonable.”

Staff told us the staffing levels were not good, they said “Due to the layout of the building we need more staff”. One staff member said “During my probation I had no probation meeting and since then I have had no supervisions. I have had online training but no face to face training apart from moving and handling.”

On our first site visit, we observed there to be no staff in the communal lounge area, due to a previous altercation between two people resulting in injury in a communal area, the management team had put a measure in place to mitigate this risk. This was a staff member being allocated to the communal lounge at all times. This action was observed as not being followed by staff. Call bells were observed to go to emergency call mode after 2 ½ minutes for numerous people.

Pre-employment checks were not completed appropriately. Disclosure and Barring certificates and references were found to be missing from staff files. We found gaps in employment and gaps in some interview notes. One staff member had not received or completed any training since commencing employment. Staff had received online training. Staff had not received ongoing supervisions in their roles and no appraisals had been offered.

One relative we spoke with about the cleanliness of the home said “No not necessarily, I have purchased a dustpan and brush so I can clear up the crumbs on (relatives) bedroom floor when I visit.”

The cleanliness of the home had improved since the last inspection. Staff were supplied with personal protective equipment. Staff were aware of infection prevention and control measure. The kitchen was clean and cleaning records were in place.

Waste bins outside, including clinical waste bins, were overflowing and had no keys to be locked therefore left unsecure. We found a laundry service stored in a plastic storage shed outside. However improvements had been made inside the building since our last inspection.

During our assessment we found that one IPC audit had been completed in a 3 month period, the audit the provider told us these would be introduced regularly. The audit did not contain actions and timescales.

People did not raise any concerns about their medicines with us. One person said, “The staff give me my medicines regularly.” However, some PRN protocols were missing or of poor quality. Medication profiles were not person centred and lacked details on how people liked to be supported with their medication.

Staff were responsible for administering medication who were not appropriately trained and supported in their roles. One person had not received their medication as prescribed, staff had delayed in seeking medical advice. Staff administered medication to one person, this medication was a known allergy. Staff had not identified this and continued to administer this medication, therefore putting the person at risk.

Medicines were not managed safely. There were gaps in the administration records. PRN protocols did not contain enough information for staff to administer medicines safely. Topical medicines and an inhaler were found unsecured in people’s rooms. This posed a risk to people living with Dementia in the service who were known to walk without purpose.