What the CQC found at The Old Vicarage

Staff had completed mandatory training and were observed supporting people safely with moving and handling. Staff said they felt supported to complete training.

“Staff were observed to provide safe moving and handling support. This demonstrated staff had received appropriate moving and handling training.” from the report

People were offered drinks, snacks and choices at mealtimes. The home monitored weight and made referrals when people lost weight or needed specialist support.

“People were supported to eat and drink enough. We observed people to have plenty of drinks and snacks offered throughout the day.” from the report

The home was no longer in breach of the regulation about consent. Capacity assessments, best-interest decisions and Deprivation of Liberty Safeguards records were in place where needed.

“The service was 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

The provider checked references, employment history and criminal record information before staff started work.

“Staff were recruited safely. This included seeking references, full employment history and completing Disclosure and Barring Service (DBS) checks prior to staff commencing employment.” from the report

Some people missed medicines, received them at the wrong time or had incomplete medicine records. One person was at risk of an overdose because doses were not always at least six hours apart.

“People did not always receive their medicines as prescribed.” from the report

Care plans and risk assessments were not always updated after falls or other significant events. Records about daily care, diabetes monitoring and emergency evacuation were also incomplete or inaccurate.

“This meant staff did not have accurate information in order to provide safe care.” from the report

The staffing tools did not always reflect people's actual needs, including the need for two staff during hoisting. Staffing was not increased after incidents linked to poor supervision.

“The provider failed to ensure an effective system was in place to calculate and review safe staffing levels. placed people at risk of harm.” from the report

Some audits were unfinished or failed to identify known problems. Action plans did not always state who would act, by when, or how completion would be checked.

“Governance systems to identify and manage risks and drive improvement were ineffective placing people at risk of harm.” from the report

There were no residents' meetings or surveys, and relatives were not routinely asked for their views. The provider also did not clearly explain how it was making improvements after the previous inspection.

“People were not provided with opportunities to feedback. There were no residents' meetings or survey's for people.” from the report

The home was clean and staff used protective equipment safely, but night cleaning schedules were not always completed. This problem had also appeared in audits without being fixed.

“However, night time cleaning schedules were not always completed to evidence required cleaning, including increased cleaning of high touch points to prevent infection, had been completed.” from the report