What the CQC found at The Old Vicarage

The home was mostly working within the Mental Capacity Act principles. Appropriate legal authorisations were in place where needed, and work had begun on further assessments and best-interest decisions.

“We found the service was mostly working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report

After inspectors raised concerns, the provider increased staffing and arranged relevant training. The provider also worked with CQC to address urgent risks.

“When we brought these concerns to the providers attention, they promptly increased staffing levels and implemented relevant training for staff via their 4 in-house trainers.” from the report

Inspectors found that fire safety checks were in place and that there was a system to reduce the risk of legionella bacteria in the water system.

“Checks for fire safety were in place. There was a system to reduce the risks of legionella bacteria in the water system.” from the report

The provider accepted the failings and worked with CQC. It appointed a care consultancy company to support longer-term improvement.

“The provider was open and honest about the failings in the service, and worked with CQC to rectify immediate risks” from the report

Risk assessments and safeguards were incomplete for falls, diabetes and choking. Inspectors also found unsafe environmental features, including sharp-edged items and an unlocked area with a drop in front of it.

“Systems and processes did not demonstrate risks were always identified, assessed and mitigated. This placed people at risk of harm.” from the report

One person received incorrect doses of a high-risk medicine on two occasions. Other medicines were given late, and records and instructions for some medicines were incomplete.

“for one person, on two recent occasions incorrect doses of their high-risk medicine to help prevent blood clots had been given to them placing their health and welfare at risk.” from the report

There were not enough suitably skilled staff on shifts. People sometimes waited a long time for help, and some staff had not completed mandatory training.

“Sufficient numbers of staff were not provided on shift.” from the report

Inspectors found several areas unclean, including bedrooms, communal areas, the main kitchen and laundry. Not all staff had infection control training and PPE was not always disposed of safely.

“People lived in an unclean environment and were not protected from the risk and spread of infection.” from the report

The home could not assure inspectors that staff were safely recruited. DBS checks for two staff members dated from 2004, and two recruitment files did not contain photo identification.

“Not having robust recruitment checks in place meant the provider could not be assured that staff were fit to work with vulnerable people.” from the report