CQC report explained · a residential care home
What the CQC found at The Vicarage Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found safe care but too few personalised activities and weaknesses in learning from incidents.
This was an unannounced follow-up inspection on 3 May 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment, safety and management records.
The home was rated Good for Safe. People felt safe, staffing levels were sufficient, recruitment checks were completed, and medicines were stored and given safely. Care records were detailed, but people and relatives were not always involved in planning their care.
The home was rated Requires Improvement for Responsive and Well-led. Inspectors found too few activities based on people's preferences, limited evidence that incidents and audits led to learning, and some people did not know how to complain. The home remained in breach of Regulation 9, as it had been at the previous inspection.
People felt safe
People told inspectors they felt safe at the home. Staff knew how to raise safeguarding concerns.
“People told us they felt safe living at the home.” from the report
Safe medicines practice
Medicines were stored and administered safely. Records and as-required medicine instructions gave staff detailed guidance.
“Medicines were stored and administered safely and there were systems and processes in place of disposing medicines securely.” from the report
Staffing and recruitment
Inspectors found enough staff to meet people's needs, and required recruitment checks had been completed.
“All required checks had been undertaken prior to people commencing employment.” from the report
Warm staff culture
Inspectors saw pleasant and accommodating staff and a relaxed atmosphere. People and relatives spoke highly of the manager and staff team.
“There was a very warm relaxed atmosphere throughout the home.” from the report
Too few personalised activities
seriousThe activity plan was not being followed consistently. People wanted activities such as gardening, but inspectors found little other stimulation between scheduled visits.
“There was an activity planner in place, but we saw little evidence that this plan was being followed.” from the report
Regulation 9 breach
seriousThe provider did not ensure care was designed around people's needs and preferences. This was a continued breach from the previous inspection.
“The provider had failed to ensure the care was designed to meet people's needs, taking their preferences into account.” from the report
Limited learning from incidents
needs fixingIncidents were recorded, but there was limited evidence that lessons were used to prevent similar risks. Inspectors made a recommendation about this.
“However, systems could be improved to ensure lessons are learnt following on from an incident to prevent future risks.” from the report
Care planning involvement
needs fixingCare records were detailed and person-centred, but people and relatives were not always involved in creating their care plans.
“However, people and their relatives were not always involved in the care planning process.” from the report
Complaints information
minorA complaints system existed, but some people and relatives did not know how to use it.
“Whilst a number of people told us they knew how to make a complaint should they need to, others said they were not aware of the procedure.” from the report
- 01What activities are now available each week, and how are they matched to each person's interests and preferences?
- 02How will you show that the new activity coordinator has improved people's social stimulation?
- 03How are residents and relatives now involved in writing and reviewing care plans?
- 04What changes have you made so lessons from accidents, incidents and audits are recorded and acted on?
- 05How will every resident and relative receive and understand the complaints procedure?
This was an unannounced follow-up inspection of Safe, Responsive and Well-led; the report gives no ratings for Effective or Caring. This explanation was written from the published report of 19 May 2023 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, February 2021
Targeted inspection not rated; The Vicarage Residential Care Home's overall rating remains Requires Improvement, with improved safety and infection control found.
This was a targeted inspection about infection control, risk management, care and record keeping. An inspector visited without notice on 18 January 2021 and followed up by telephone on 20 January 2021.
Inspectors found that risks, including falls, were well managed. New systems gave staff clearer instructions about checks after falls or illness, medical support and record keeping. They found no evidence that people were at risk of harm from the concerns being checked.
Infection control arrangements were judged good. The home had suitable protective equipment, regular COVID-19 testing, cleaning procedures and a visitor pod. Access to the pod was still being improved with a level access ramp.
This inspection was not a full reassessment and did not change the rating. The overall rating remained Requires Improvement, based on the previous inspection. The Safe question was inspected but not rated.
Infection control
Inspectors were assured that the home was using protective equipment safely, carrying out testing and following infection control guidance.
“We were assured that this service met good infection prevention and control guidelines.” from the report
Managing risks
Risk assessments gave staff clear guidance about keeping people safe while respecting their choices.
“Risks to individuals and staff were identified and well managed.” from the report
Falls and illness procedures
The home had introduced a clearer process for checks after falls or illness, including when to seek medical support and how to record observations.
“Improvements had been made to the systems and processes for post falls and illness management and observations.” from the report
Clean environment
The environment was described as clean, well lit and free from clutter, with detailed cleaning procedures.
“The environment was very well lit, clean and clutter free.” from the report
Visitor pod access
minorThe home had provided an external visitor pod, but access was still being improved by installing a level access ramp.
“The provider was in the process of improving access to the pod by installing a level access ramp.” from the report
- 01What improvements were made after the previous comprehensive inspection, and what still needs to be completed?
- 02Has the level access ramp to the external visitor pod now been installed?
- 03How are checks after a fall or illness recorded, and when would medical support be sought?
- 04How often are routine wellbeing checks carried out and reviewed?
- 05How are accidents and incidents monitored, and what changes have been made as a result?
This was a targeted inspection of specific concerns under Safe, including infection control, risk management, care and records; the full Safe question and the other four questions were not assessed. This explanation was written from the published report of 10 February 2021 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 Vicarage Residential Care Home
6 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- May 2023Requires improvementcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at The Vicarage Residential Care Home →
- February 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at The Vicarage Residential Care Home →
- August 2020Requires improvementstayed Requires improvementSafe: Good
- October 2019Requires improvementup from InadequateSafe: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2019Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2018Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- January 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 27 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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