CQC report explained · a residential care home
What the CQC found at The Old Vicarage
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found unsecured medicines, environmental risks, poor recording of incidents and weaknesses in safeguarding investigations. There were enough staff and recruitment checks were in place.
- Effective?
- Requires improvement
- Mental Capacity Act and Deprivation of Liberty Safeguards requirements were not always met. Weight monitoring, dementia-friendly design and some care records also needed improvement.
- Caring?
- Requires improvement
- People's privacy, dignity and independence were not always respected. People and relatives were not consistently involved in care reviews or asked for their views.
- Responsive?
- Good
- This question was not inspected during this visit. The previous rating was used to calculate the overall rating.
- Well-led?
- Requires improvement
- Quality checks did not identify or address several problems. Records, notifications to CQC, policies and care plan reviews were not consistently managed.
What inspectors found, February 2024
Rated Requires Improvement; inspectors found risks with medicines, safeguarding, dignity and quality checks.
The inspection was unannounced and took place on 11 January 2024. Inspectors and an expert by experience spoke with people, a relative and staff. They reviewed care records, medicines records, policies, procedures and audits.
The home had enough staff and recruitment checks were in place. People and relatives said they felt safe and staff were generally kind and helpful. However, inspectors found medicines were not always managed safely, risks were not always controlled, and infection prevention practices were inconsistent.
People's privacy, dignity and involvement in care were not always protected. The home also had weaknesses in mental capacity and best-interest processes, care reviews, safeguarding records and quality monitoring. The overall rating and all four inspected questions changed from Good to Requires Improvement. Responsive was not inspected and its previous rating was used.
Staffing and recruitment
Inspectors found enough staff to meet people's needs during the visit. Recruitment checks were in place.
“There were enough staff to meet people's needs and staff were recruited safely.” from the report
People felt safe
Although inspectors found safety problems, people they spoke with said they felt safe in the home.
“Despite our findings people told us they felt safe.” from the report
Staff training
Staff received induction, training and competency checks in areas such as moving and handling.
“Staff received induction and training and their competencies checked in areas such as moving and handling.” from the report
Access to health professionals
People were supported to see health professionals, and referrals to specialist services were made when needed.
“People were supported to access a variety of health professionals.” from the report
Medicines were not always safe
seriousSome creams were unlocked or expired, medicine records were out of date, and guidance was missing for some medicines. This increased the risk of medicines being given incorrectly.
“Medicines were not managed safely.” from the report
Risks and infection control
seriousInspectors found unsecured wardrobes, missing window restrictors, fire safety problems, unlabelled food and areas that were not clean. Staff were not always following safe infection control practices.
“The provider had failed to robustly assess the risks relating to the health safety and welfare of people.” from the report
Safeguarding and incident records
seriousUnexplained bruising had not always been investigated or escalated. Records did not properly capture incidents, so the home could not identify patterns or learn from them.
“Systems and processes were not effective in safeguarding people from potential abuse.” from the report
Privacy and dignity
seriousGlazed panels allowed people to see into some private areas, and continence information was displayed where others could see it. The provider removed signs and covered the panels after the inspection.
“Failure to have suitable arrangements in place to protect people's privacy and dignity was a breach of Regulation 10” from the report
Mental capacity and involvement
seriousA person's covert medicines did not have the required capacity assessment, best-interest meeting or staff guidance. People and relatives were not consistently involved in care reviews.
“The provider was not always working in line with the Mental Capacity Act.” from the report
Weak quality monitoring
seriousAudits had not identified the problems found by inspectors. Care reviews, records, statutory notifications and action plans were not consistently managed.
“The systems the provider had in place to monitor quality and safety were not effective and had not identified the concerns found on this inspection.” from the report
- 01What has been done to make sure all medicines, including creams, patches, covert medicines and as-required medicines, are stored, recorded and administered safely?
- 02How are safeguarding concerns, unexplained bruising, accidents and incidents now recorded, investigated and reported?
- 03How will you protect residents' privacy and dignity, including private room and bathroom areas and continence information?
- 04How are Mental Capacity Act assessments, best-interest decisions and Deprivation of Liberty Safeguards authorisations checked and kept up to date?
- 05What is the timetable for completing the CQC action plan and showing that audits and care reviews are identifying and fixing problems?
This was a focused inspection of Safe and Well-led, widened to include Effective and Caring; Responsive was not inspected and its previous rating was carried over. This explanation was written from the published report of 29 February 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, September 2017
The Old Vicarage was rated Good; inspectors found safe, kind and personalised care, but one complaint was not handled effectively or promptly.
This was an unannounced comprehensive inspection. Two inspectors spoke with people living in the home, staff and a visiting health professional. They reviewed care and medicines records, other management records, and observed care in communal areas.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from harm, supported by enough staff, and given their medicines safely.
People were supported by trained staff who respected their choices, privacy and dignity. Their care was tailored to their needs, and they could take part in activities they chose. The home also had systems to check the quality of care.
The overall rating stayed Good, the same as at the previous inspection on 12 May 2016. Inspectors identified one complaint that had not been investigated effectively or dealt with in good time.
People felt safe
People consistently told inspectors they felt safe. Staff understood safeguarding and the risks people faced.
“People consistently told us they felt safe living at The Old Vicarage.” from the report
Enough staff
Inspectors found staffing levels were enough to meet people's needs and respond in a timely way.
“People were supported safely and their needs met by sufficient numbers of staff.” from the report
Kind and respectful care
Staff treated people warmly and respected their privacy, dignity, choices and independence.
“People continued to receive support from staff who were kind, caring and compassionate.” from the report
Personalised support
Care plans included people's backgrounds, preferences and specific needs. People could choose activities and how they spent their time.
“People's care and support was tailored to meet people's individual needs and preferences.” from the report
Good oversight
The manager used meetings, checks and feedback to monitor the quality of care and identify improvements.
“There were systems in place, which continued to monitor and assess the quality of the service provided.” from the report
Complaint handling
needs fixingOne complaint had not been investigated effectively or dealt with promptly. The manager acknowledged this and said future complaints would follow the home's procedures.
“We were aware that the home had received one complaint, which had not been investigated effectively or dealt with in a timely manner.” from the report
- 01How will you make sure complaints are investigated properly and dealt with within a reasonable time?
- 02What staffing levels are normally provided on each shift, and how do you cover sickness or other absences?
- 03How will you assess and review my relative's individual risks, care needs and preferences?
- 04How are medicines checked, recorded and reviewed for each person?
- 05What activities and community links would be suitable for my relative?
This was an unannounced comprehensive inspection covering all five CQC questions, with ratings continuing as Good from the previous inspection. This explanation was written from the published report of 8 September 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of The Old Vicarage
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- February 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- September 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodWell-led: Good
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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Most charge £960 to £1,410 a week. 10 can care for a couple. 8 years' experience on average.
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