We carried out an unannounced inspection of Vicarage Residential Home on 20 and 22 March 2018. Vicarage Residential Home is a ‘care home’ without nursing. Nursing care, if needed, is provided by the community healthcare team. People in care homes receive accommodation and personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Vicarage Residential Home accommodates up to 35 people in one adapted building. At the time of our inspection there were 29 people living at Vicarage Residential Home.

There was a registered manager at the service. They were supported by a deputy manager. Both had worked at the service for many years. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. People and relatives said of the management team, “All the staff are very approachable", “This place is a home from home", “The managers are as good as gold", “It’s the best home I've stayed in" and “The staff and management are excellent. There's good communication from them, they always phone if something is wrong. I have peace of mind."

Following the last inspection in March 2017, we met with the provider to discuss the concerns raised at the last inspection because we had rated the service as requires improvement overall. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, responsive and well led to at least good. There were concerns about safe recruitment of staff, adequate staffing levels at night, the admission assessment process and the effectiveness of quality assurance processes.

During this inspection in March 2018, we found all concerns had been addressed and we rated the service as good in all domains and overall. At this inspection we found the service was meeting all regulatory requirements and we did not identify any concerns with the care provided to people living at the home.

On the day of the inspection there was a calm and relaxed atmosphere in the home and we saw staff interacted with people in a friendly and respectful way. People were able to choose what they wanted to do and enjoyed spending time with the staff who were visible and attentive. There was a lot of staff interaction and engagement with people, some of whom were living with dementia and unable to tell us directly about their experiences. They looked comfortable and happy to spend time in the large lounge/conservatory or choose to spend time in their rooms. People were encouraged and supported to maintain their independence. There was a sense of purpose as people engaged with staff, watched what was going on, played games and pottered around the home. Staff engaged with people in ways which reflected people's individual needs and understanding, ensuring people mobilised safely from a discreet distance.

People were provided with good opportunities for activities, engagement and trips out. People could choose to take part if they wished and when some people preferred to stay in their rooms, staff checked them regularly spending one to one time with them.

People and relatives said the home was a safe place for them to live. Comments included, “They make sure mum always has her call bell on hand", “They stay and make sure I have taken my medication", “I have my door open so the staff can see I am safe and ok” and “The staff are so kind, they make me feel safe." Staff had received training in how to recognise and report abuse. All were clear about how to report any concerns. Staff were confident that any allegations made would be fully investigated to ensure people were protected. Any safeguarding concer

The inspection took place on the 28 and 29 March 2017 and was unannounced.

The Vicarage Residential Home is registered to accommodate a maximum of 35 older persons. They provide residential care without nursing. Nursing care if needed is provided from the community team. There were 33 people living at the service when we visited. The Vicarage also provided short term respite care for people.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on the 23 June 2016 we found some concerns and areas where improvement was needed. We found medicines were not always managed safely, and people did not always receive their medicines at the time they needed them. The number of staff available were not sufficient to meet people’s needs safely. People also told us there were limited opportunities or activities available to occupy their time, and we were told the service was not always well- led. The provider wrote to us and told us how they planned to address these concerns and by when. We found at this inspection that improvements had been made in relation to activities and the management of people’s medicines. However, improvements were still needed in relation to staffing, and the leadership of the service.

Although the registered manager and provider told us action had been taken to address concerns relating to staffing, people and staff still said there were still times when staffing at night was not sufficient to meet people’s needs and to keep them safe. The registered provider and registered manager told us staffing levels had been increased when the number of people in the home increased. However, we saw no evidence of an effective system to review staffing levels regularly based on people’s needs.

People were supported by staff who had undergone sufficient checks before starting work in the home. However, people were not fully protected as systems were not sufficient to monitor and address risks, which had been identified in relation to staff supporting them.

The registered manager and provider undertook a range of audits to assess and monitor the quality of the service. They said they also met with people and staff regularly to discuss any issues and improvements required. However, these had not in all cases been effective in identifying shortfalls and gaps in staffing and records. Following the inspection the registered manager wrote to us and told us how they had improved the quality auditing process to include regular reviews and monitoring of staffing levels.

People told us about the different activities now available and an activities coordinator had been employed to improve the social opportunities available to people. However, information in people’s support plans about their backgrounds and interests had not always been completed, which could mean this information was not known to staff planning their care.

The admissions process required some improvement to help ensure people received consistent care as they moved between services. When people were admitted from hospital information had not always been gathered in relation to other aspects of their life, such as where they had previously lived. The absence of this information could mean important issues relating to people’s life and lifestyle would not be known or form part of their on-going plan of care.

Healthcare professionals said the registered manager and staff had worked hard to improve links between the home and healthcare professionals. They said the registered manager and staff had listened to advice and had improved records, communication and staff training. This had resulted in people’s health care

The inspection was carried out on the 23 June 2016 and was unannounced. We carried out a focused inspection of the service on 12 September 2015 where we found concerns in relation to people being woken before 6am. Prior to this inspection we received further concerns about staffing levels, people being woken before they wished, the cleanliness of the home, staff conduct and concerns about the leadership within the service. During this inspection we looked to see if improvements had been made and we found that action had been taken. However, we found staffing levels were not always sufficient to meet people’s needs and aspects of people’s medicine management were not safe.

Vicarage Residential Home is registered to accommodate a maximum of 35 older persons. They provide residential care without nursing. Nursing is provided from the community nursing team as required. There were 31 people living at the service when we visited.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were not sufficient staff on duty at all times to ensure people’s needs were met. All staff we spoke with during the inspection expressed concerns about the staffing levels over recent months, particularly at night. Staff had been covering cooking, cleaning and laundry duties due to vacancies and sickness. However, five new staff were going through recruitment checks which would ease some of the staffing issues we found. We spoke to the registered manager about people’s and staffs feedback and following the inspection were advised a meeting with the providers had been arranged to discuss safe staffing levels.

People’s prescribed medicines were largely administered as prescribed. However, the service was piloting a new electronic medicine system which was causing some difficulties affecting people receiving their medicine safely. The registered manager was working to resolve issues and make improvements.

People told us activities were limited. Most people had little meaningful stimulation throughout the day. Staff told us they did not have time to do activities with people. The registered manger told us with budgetary cuts, providing individualised activities was not possible. This was an area he and the provider wanted to improve.

The home was clean and infection control procedures were followed. Some areas of the home had an odour but the registered manager was taking action to address this. Staff told us they were unable to keep up with the laundry duties. The registered manager was aware of staff concerns and was taking action to increase the laundry facilities to support staff.

Staff treated people with kindness and respect. We observed staff treating people with patience and supporting people in their own time. People were complimentary about staff and how they treated them. They also confirmed staff always asked for their consent before commencing any care. Staff always protected people’s dignity while delivering personal care. People unable to consent to their care were being assessed in line with the Mental Capacity Act 2005.

Staff were recruited safely and underwent training to ensure they could effectively meet people’s needs. New staff underwent an induction and shadowed experienced staff. Staff were knowledgeable about identifying safeguarding concerns and understood how to raise concerns. All staff we spoke with stated they would raise these with the registered manager and felt they would be addressed. If not, they felt able to whistle blow and knew who to contact if this was required.

People and staff felt they could raise any concerns or issues about the standard of care or suggest changes about

We carried out an unannounced comprehensive inspection of this service on 7 & 8 May 2015.

Following the comprehensive inspection of 7 & 8 May 2014 we received information about concerns in relation to the service. As a result we carried out a focused inspection on 12 September 2015. The concerns were about people being woken and got up from 4am, staffing levels within the service and moving techniques used by staff. We also received concerns about the cleanliness of the environment and people not being attended to in an appropriate time, with call bells being left unanswered.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Vicarage Residential Home on our website at www.cqc.org.uk.

Vicarage Residential Home is registered to accommodate a maximum of 35 older persons. They provide residential care without nursing. Nursing is provided from the community nursing team as required. There were 35 people living at the service when we visited.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We visited early in the morning, from 5.45 a.m. until 9.30 a.m. and found six people already up and dressed and the two care staff on duty assisting a seventh person with personal care. Staff confirmed they had received manual handling training.

People were observed to have call bells within reach. As staff were busy with people who required two staff to assist them, other people needed to wait for assistance. One person said; “I’d love a cup of tea but have to wait until breakfast.” They said this was because staff were busy in the morning.

People’s care records held information about how people wished to be supported. However for people who were unable to give consent we did not find information recorded on the time they liked to get up in the morning.

People were in a service that was clean and maintained.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see what action we told the provider to take at the back of the full version of this report.

We considered our inspection findings to answer the question

Is the service safe?

This inspection was carried out to assess how medicines were handled and managed in the home. This was to follow up on some issues that were found at a previous inspection.

This is a summary of what we found-

Is the service safe?

We found that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. Improvements had been made since our previous inspection and medicines were now handled and managed safely.

We visited Vicarage Residential Home twice in 2013 (referred to as ‘the home’ in the report). In August 2013 we raised serious concerns about the home and returned in October 2013 to ensure progress was being made. Following our previous visits we asked the provider to send us an action plan each time detailing how they were going to address the concerns. We also requested an updated action plan in January 2014 to ensure progress was being maintained. We were advised the home would have addressed the concerns fully by the end of March 2014. When we visited this time we followed up to ensure that the home had addressed the outstanding concerns.

Our team was made up of two inspectors, a pharmacist inspector and an expert by experience (who was a lay person with knowledge of care homes). We spent the day at the home and spoke with people who lived in the home, visitors, staff, professionals with knowledge of the home and the manager running the home. We also read paperwork detailing people’s care (called care plans) and the running of the home.

There were 34 people living at the home when we visited.

As part of our inspections we look to see that the service is

• Safe

• Effective

• Caring

• Responsive

• Well led

A summary of what we found can be found below.

Is the home safe?

During our previous visits in 2013 we raised serious concerns about how safe people were in the home. When we visited this time we found there had been a high level of improvement in this area.

We were told “I feel safe here, I’ve never known such kindness.”

We found the home had active and up to date policies in place to ensure people were protected from the risk of harm. Staff had undergone relevant training, supervision and appraisal. For example, staff were trained in safeguarding vulnerable adults. People told us they felt safe and would speak to the manager if they had an issue or concern.

We saw the home involved people in the running of the home and sought their view or opinion of their care. We saw that other issues were due to be discussed at a forthcoming residents’ meeting.

People’s care needs were reflected in their care plans and people told us their needs were being met. The documentation of this care was clear and up to date. There were regular reviews and risk assessments completed to ensure people’s needs continued to be met. Visitors and professionals also told us they felt people were safe and well cared for.

We have concerns in respect of the safe administration of medicines that we judged were having a minor impact on people. We have asked the provider to provide an action plan and date when they will have addressed the concerns.

We found the home was aware of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) and were seeking a review of all people who did not have the capacity to consent to their care. Following national changes to DOLs they were applying to the local authority following our visit.

Is the home effective?

We found that the care planning system in place demonstrated that the home was effective in delivering care that met people’s assessed needs.

People were involved in running the home and had been instrumental in setting up a residents’ fund and summer fete.

Staff were well supported and trained. They were able to relate how they were meeting people’s needs and fulfilling their care role.

Is the home caring?

We saw that the staff related to people with care and kindness. Humour was used carefully and appropriately.

We found that people were treated with respect and were addressed by their chosen form.

People told us “The food is lovely, I have a choice of food and I get help at mealtimes as it is difficult for me to feed myself”, “I can have a bath whenever I want one, my hair is done every week and I see the chiropodist monthly”, “My privacy is respected”, “I can’t fault the home or the staff, we have no complaints” and “I consider the care staff friends of mine.”

Is the home responsive?

Following our visits to the home in 2013 we were in contact with the home regularly. We found that the home was responsive to the concerns and responded to requests for information from both the local authority and the Care Quality Commission. For example, they sent us an updated action plan in January 2014 so we could ensure progress was being made and maintained.

We found that people’s care plans and risk assessments were regularly reviewed. When concerns were raised we saw that people’s needs were assessed. For example, we saw that people had been reviewed by district nurses, occupational health and their GP.

On the day we visited the home had one less care worker than planned on duty in the day. We saw that senior staff and the manager were on the floor supporting care and various visiting professionals. Where people’s care was delayed we found that people were being told and updated.

People told us they were able to rise and retire as they desired. One person told us they had been moved to a room in a more sociable area of the home when they requested it. They told us how this had reduced their feelings of isolation. They told us they had also requested their bedroom door be left open so they could make the most of the opportunities to speak to staff and other people in the home.

Professionals we spoke with told us they found the staff to be knowledgeable of people’s needs and always able to respond to questions. A paramedic attending the home the day we visited told us they were impressed by the staff member who supported them stating “There was a sense of everything being under control.”

Is the home well led?

When we visited the home in 2013 we raised serious concerns about how the home was being run. When we visited this time we found there had been improvement in this area.

On the day we visited there was a manager, a deputy and senior carer on duty. This was extra to the care staff delivering day to day care. We found there was a clear staffing structure in place. Staff both told us they felt the manager was approachable. Most people told us they felt the home to be run well and better than before. The GP told us the home had “Undergone a lot of transition but was getting better. There is a lot more policy and structure in place.” One resident told us they preferred the previous manager, but everyone else we spoke with told us they felt the home to be well led.

We found that the home had put in place a comprehensive list of policies, procedures and practices to ensure the quality of care was built on a foundation. The associated audits ensured this was maintained. For example, we found that the care plans were reviewed monthly and the associated risk assessments and paperwork updated as required.

We heard “I can’t fault the home or the staff, we have no complaints”, “I live abroad and visit whenever I can; I feel that Mum is getting good care.”

The main concern people raised with us was their not being involved in the planning of the menu and the delay it took for food to be transferred from the kitchen to the dining room. We were told this would be addressed at the next residents’ meeting due to take place two weeks following our visit.

There was not a Registered Manager currently in place. We discussed this with the current manager during our visit and were assured that this would be an action they would complete as soon as possible.

We carried out an inspection at Vicarage Residential Home on the 1, 2 and 6 August 2013 and we had concerns about the care of the people living within the home. We referred our concerns to the local authority safeguarding and commissioning teams and have worked closely with them to ensure people were safeguarded and their welfare protected. We also met with the provider on the 9 August 2013 and requested they produce an action plan to detail how they were going to address the concerns and ensure people’s needs were being met within the home. This gave us an oversight on how the provider was going to address the concerns.

The previous manager is no longer in post at the home and a new manager and deputy have been appointed. We met with the new manager on 30 September 2013 and requested a new, refined action plan with dates when they believed they were going to be able to put things right. We were told the final date for completion of the actions required would be 10 November 2013. This was in respect of introducing a new care planning system. They told us they had already addressed many of the concerns in many areas we had identified in August.

Our visit to the home on 14 October 2013 was carried out to check on the progress against the action plan and to ensure that we were satisfied that progress was being made and people’s welfare needs were being met while the planned changes were being implemented. We also, wanted to speak to the people living in the home, family members and health and social care professionals with knowledge of the service to ensure they felt that the situation was improving.

We found there had been improvement in each of the 11 areas of concern we reviewed during this visit. We judged the management of medicines and record keeping at the same level as when we visited in August 2013 as they had yet to reduce our concerns sufficiently in those areas. We found the progress in respect of diet and nutrition, staffing levels, how staff were recruited and notifications of other incidents were now met and our concerns alleviated.

People and family told us they felt the home had improved and voiced their confidence in the new manager and deputy manager. People told us they were happy with their care and family members told us that even though they had considered moving their family members when the concerns arose they were happy they had not done so.

We spoke to four people who used the service and four members of staff. One person said that the care that they received was "Excellent, the girls are really good to me." Another person said "Not all the carers are good but on the whole it is good here." We saw that the provider took account of what activities people wanted to undertake and that they had taken steps to address individual requests.

We found that people who used the service were informed about the care planned for them and they felt able to be part of the care planning process. Care records showed that people had signed to state that they agreed to care given. Care records were well maintained and reflected current care given.

Although the home was in need of refurbishment and plans for this were due to commence, the home was clean. There was an infection control policy in place which reflected current guidance. A small team of cleaners maintained the home which was odour free in most parts. Staff were well supervised and had been employed at the home for a long time. The newest member of staff had been employed for over one year.

The home has an effective complaints process which people are aware of. Most complaints are dealt with informally by the registered manager. CQC recieved a complaint in March 2013 and passed the infromation onto the provider. We saw that this complaint had been appropriately responded to.

On the day of our visit we walked around the home and spoke with 11 of the people that use the service. We also spoke with managers and staff and with visiting professionals.

People told us that Vicarage Residential Home was “wonderful” and said “it’s great here". One person said she got “treated better than the Queen”. We asked people what made the care given by the home so good. People told us that all of the care and support they received was good and that the staff were friendly, helpful and patient. They also said that the food was good and that they were given choice in how they wanted to live at the home. Throughout this visit we saw staff talking to people in a kind and friendly way and caring for people in a polite and professional manner.

We spoke with a person who has an active life both in and outside the home. They said that they had the freedom to live as they wished and to make their own choices.

Another person who had complex care needs told us that the service was doing everything possible to support them and that the staff cared for them with sensitivity, efficiency and good humour.

The staff said that they enjoyed working at the home and supporting the people that lived there. We spoke with a visiting District Nurse who said they were pleased with the way in which peoples’ health was cared for by the home and that they could rely on the service to contact them when necessary and to carry out all the care that needed to be delivered.

The people that live in this care home had varied care needs and some of the people had multiple support needs. We saw that the service had the necessary staff on duty throughout both the day and the night to support the people that lived at the home.

The staff ensure through the way they deliver care and support that everyone’s human rights, privacy and dignity were respected and protected. For example we saw staff talking with people in a happy but also respectful manner and we saw support being offered with sensitivity and care.

We heard about peoples’ daily activities and how the service is working effectively to provide people with stimulating activities that they will enjoy.

We saw that the home was clean and hygienic throughout and that the building and facilities were being adequately maintained.

Some of the care planning documentation that was being used could be improved in order to better support the delivery of care and a few of the records could also be better maintained.

The inspection was carried out on the 7 and 8 May 2015 and was unannounced. We previously inspected the service on 22 April 2014 where we found concerns in relation to the safe administration of medicines. We reviewed this on the 15 July 2014 and found our concerns had been addressed.

Vicarage Residential Home is registered to accommodate a maximum of 35 older persons. They provide residential care without nursing. Nursing is provided from the community nursing team as required. There were 34 people living at the service when we visited however, one person was in hospital.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us there were issues with staffing since January 2015 which had led them to be concerned. People said there had been a high turnover of staff and staff were very busy. They stated their care needs had been met but two people said they had issues with so many new faces and trying to remember staff names. Records, staff and the registered manager confirmed there had been issues with high staff sickness rates and retaining staff during this time. Staff told us they had worked extra shifts. The registered manager and deputy manager had taken on care roles during this time. This had a direct impact on being able to ensure some records such as people’s care plans and risk assessments were up to date. Also, supervisions and appraisals of staff had been postponed as meeting people’s care needs were prioritised. We saw on inspection that more staff had been recruited and people and existing staff confirmed this had improved. The registered manager and deputy manager had plans in place to address the shortfall in records and staff supervision and appraisals.

People’s prescribed medicines were largely administered as prescribed. However, we identified concerns about how people’s prescribed creams were being administered and monitored. The recordings on some people’s medicine administration records were difficult to read. We have had contact with the registered manager since the inspection who has advised that all these issues have been addressed. We have however recommended they read the current NICE (National Institute for Health and Care Excellence) guidance to ensure the practice of administering medicines is in line with current standards.

People felt in control of their care and deciding how they wanted their needs to be met. People had risk assessments and care plans in place which were person centred and reflected their needs. However, as identified above, some of these required updating to reflect people’s current status. During the inspection, we saw this had been identified and was being addressed. Records showed and people confirmed that people had their nutrition and health needs met. Other professionals were requested to assess and give guidance to staff if there were any concerns. Records showed these were followed and staff confirmed staff handovers between shifts gave them the information they needed to meet people’s needs. The health professionals we spoke with confirmed they were impressed by the level of knowledge staff had of people’s needs even if they had only lived there for a short time.

Staff treated people with kindness and respect. We observed staff treating people with patience and supporting people in their own time. People were complimentary about staff and how they treated them. Any issues were related to the staffing issues which had been identified. They also confirmed staff always asked for their consent before commencing any care. Staff always protected their dignity while delivering personal care. People unable to consent to their care were being assessed in line with the Mental Capacity Act 2005.

Staff were recruited safely and underwent training to ensure they could effectively meet people’s needs. New staff underwent a detailed induction and shadowed experienced staff. Staff were knowledgeable about identifying safeguarding concerns and understood how to raise concerns. All staff we spoke with stated they would raise these with the registered manager and felt they would be addressed. If not, they felt able to whistle blow and knew who to contact if this was required.

People and staff felt they could raise any concerns or issues about the standard of care or suggest changes to the service. The registered manager had systems in place to pick up on people’s concerns or complaints. People were spoken with about this and whether they were happy with the outcome which was clearly documented to show they were.

The provider and registered manager regularly checked the quality of the service to ensure standards were being maintained to an appropriate level. A number of audits were completed to measure this. People and staff were asked for their view.