The Old Vicarage

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• 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

The provider had not implemented effective governance and systems, therefore the provider did not have clear oversight of the service. Staff had not received frequent supervisions and no appraisals in the last 12 months, this meant staff were unable to set goals and achieve their professional aspirations. There was a high turnover of managers since the last inspection. implementing more robust governance processes would support the provider to have increased oversight of the running of the service, identify issues earlier to improve the quality of care and treatment, and provide opportunities for learning.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke with the Nominated Individual and Care Consultant. They were unable to provide evidence of an action plan of improvement or direction. They had not completed the actions from the previous CQC inspection. The Care Consultant confirmed that they had recently started their role at the service shortly before we announced the assessment. They confirmed the had not had time to implement actions or new systems.

The Care Consultant confirmed that they had recently started their role at the service shortly before we announced the assessment. They confirmed they had not had time to implement actions or new systems.

Feedback from staff was mixed as there had been a high turnover of managers and they felt there had been a lack of consistency from the management team. One staff member said, “Staff morale is alright, some people (staff) are not always happy”. Another staff member said, “There is no communication from management”.

Since the last inspection in June 2023, there have been numerous managers in post. There was not a registered manager in post at the time of our assessment. The provider had employed a Care Consultant to complete the managerial day to day tasks in the service prior to the assessment being announced

Staff were knowledgeable on the procedure they needed to follow to raise concerns. One staff member said, “I have raised one concern, I felt I was listened too, and then (care consultant) acted on it.” However, another staff member said, “what management team?” “There is no structure in the running of the home. “

Policies were in place to raise concerns. However, the provider had not offered use of surveys to engage with people, relatives, or staff to gain feedback. Meetings were infrequent and did not offer agendas for staff to share ideas and views. There were no lessons learnt from incidents that had occurred.

Staff were not encouraged or supported to share ideas and give feedback on their experiences in their roles. This feedback if gained would support improvement at the service.

The provider did not have systems in place to ensure the recruitment process was robust. Staff were found to be employed without references and gaps in employment. The Nominated individual was unable to locate Disclose and barring certificates. Appraisal were not being offered; therefore, staff were unable to discuss their own professional goals and aspirations within in their roles.

Staff demonstrated a lack of knowledge in their roles and responsibilities in supporting people with the management of medicines, this led to poor outcomes for people in the service.

The provider was unable to identify and action the failings in the service. The high turnover of managers led to inconsistencies and poor system performance. Systems that were in place were ineffective. Lessons were not learnt in relation to falls risk management and bowel management and records were poor.

During this assessment we did not feel that the service was working in collaboration with the people living in the service. Referrals were not followed up, which put people at greater risk regarding their health and mobility.

Staff had not always received training, we found that night staff had not received appropriate training to support people in the event of a fire. Staff had not received competency checks in areas of their roles to better support people’s individual health needs.

During our site visit there was no concerns around external professionals working with the service.

Systems were ineffective and contributed to people’s poor outcomes. The provider had a poor oversight of the risks in the service; therefore, they were not supporting to mitigate the risks for people.

We were not assured when speaking with staff and leaders that lessons had been learnt from incidents and accidents. We did not feel training was sufficient and effective based on the needs of the people living at the service.

The oversight of the service was poor from the provider, we did not feel systems were effective in supporting the service and staff team. Staff members had not received supervisions or appraisals, therefore, unable to reflect when things went wrong. The provider did not offer regular opportunities of meetings for relatives/people and staff where views and ideas would be shared. We found that learning and improvement was poor and had an impact on the safety and quality of people’s lives.