This inspection took place on 24 and 25 September 2015 and was unannounced. It was carried out by an inspector and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.
The Old Vicarage provides care for up to 39 older people some of whom may be living with dementia. On the days of the inspection there were 39 people living at the service. The Old Vicarage is located in the village of Tilmanstone. It offers residential accommodation over two floors and has two communal areas together with a conservatory on the ground floor which is also used as a dining area. There is a secure garden at the rear and side of the premises.
There was a registered manager working at the service. 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 and associated Regulations about how the service is run. The registered manager was supported by a deputy manager.
Although people told us they felt safe, risk assessments to support people with their daily lives were not detailed enough to show how the risks should be managed safely and kept to a minimum. The assessments also lacked guidance for staff to support people with their mobility and nutrition and skin care. This left people at risk of not receiving interventions they needed to keep them as safe as possible.
People were satisfied with the care and support they received. Everyone had a care plan. The contents, information and quality of care plans varied. Care plans did not record all the information needed to make sure staff had guidance and information to care and support people in the way that suited them best and kept them safe. When people’s needs changed the care plans had not been updated to reflect the changes. Care plans did not record all the information needed to make
sure staff had guidance and information to care and support people in a person centred way.
If people were unwell or their health was deteriorating the staff contacted their doctors, district nurses or specialist services but this was not always done as quickly as it should be.
Accidents and incidents had been recorded and action had been taken to reduce the risks, however these were not analysed to identify any patterns or concerns to reduce the risk of them happening again.
Recruitment processes were in place to check that staff were of good character to work with people living at the service. Not all the safety checks that needed to be carried out on staff, to make sure they were suitable to work with people had been completed.
Some people received medicines ‘when required’, like medicines for pain or medicines to help people remain calm. There was no guidance for staff to tell them when they should give these medicines and the effects of the medicines people received was not being monitored.
The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). At the time of the inspection the registered manager had applied for a DoLS authorisation for some people who were at risk of having their liberty restricted. They were waiting for the outcome from the local authorities who paid for the people’s care and support. Not all mental capacity assessments had been completed to assess if other people needed to be considered for any restrictions to their freedom and how they were involved in planning their care. All the people using the service needed to have their mental capacity assessed to make sure consideration was given to any possible restrictions to their freedom. We have made a recommendation about the registered manager seeking advice about making sure everyone has the appropriate mental capacity assessments in place to meet their individual needs.
When people were unable to make important decisions for themselves, relatives, doctors and other specialists were involved in their care and treatment and decisions were made in people’s best interest. Mental capacity assessments and decisions made in people’s best interest were recorded.
People told us that they felt safe living at The Old Vicarage. Staff had received safeguarding training and they were aware of how to recognise and protect people from the risk of abuse. Staff knew about the whistle blowing policy and said they could raise any concerns with the registered manager, the provider or outside agencies if needed.
There were sufficient staff on duty to meet people’s needs. Staff received induction training and there was an on-going training programme. The training programme did not include some of the specialised training staff needed to make sure people received the care and support to meet their individual needs.
The service’s policy and procedures stated that staff should have one to one meetings every six to eight weeks with the registered manager or the deputy manager. Staff were receiving support from the registered manager or deputy manager through one to one meetings but the frequency of the meetings were not in line with the policies and procedures. Yearly appraisals were being held to make sure staff had the opportunity to develop and identify their training needs and develop their skills and knowledge but not all staff had received an appraisal in the last year. There were regular staff meetings so staff could discuss any issues and share new ideas with their colleagues to improve people’s care and lives.
Improvements had been made to the environment and there was an on-going plan to make sure the improvements continued. Checks on the equipment and the environment were carried out and emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do.
People told us that they enjoyed their meals. The meal portions were plentiful and people had a choice of food and drinks they wanted. If people were not eating or drinking enough their food and fluid intake was monitored. Some of the records for this were not clear. If needed a referral was made to a dietician or their doctor and food supplements were available so people were kept as healthy as possible.
People and relatives told us the staff were kind and respected their privacy and dignity. People were offered choices on a daily basis. Staff were familiar with people’s likes and dislikes such as if they liked to be in company or on their own. Staff knew what food people preferred and supported people with their daily routines. People were involved in activities which they enjoyed.
Staff were attentive and the atmosphere at the service was calm and people appeared comfortable in their surroundings. Staff encouraged and involved people in conversation as they went about their duties, smiling and chatting to people as they went by. When people became anxious or restless staff took time to sit and talk with them until they became settled.
Staff supported people to go where they wished within the service. The people and their relatives attended regular meetings to discuss the service and their care.
The complaints procedure was on display. It was assessable and available to visitors but not easily available to people living in the service, People, their relatives and staff knew how to complain and felt confident that if they did make a complaint they would be listened to and action would be taken.
There were quality assurance systems in place. Some audits and health and safety checks were regularly carried out but some checks had not been done. The registered manager had not identified and taken action to make sure the systems used by the service were checked regularly and that shortfalls were identified and improvements made. The service had sought feedback from people, their relatives and other stakeholders. However, their opinions had not been analysed to promote and drive improvements within the service.
The registered manager is required by law to notify the Care Quality Commissions (CQC) of incidents that occur at the service. The registered manager had not notified CQC of some of the incidents that had happened at the service like safeguarding issues and serious injuries.
We received mixed information about the management of the service. The CQC had received concerns about the management approach from various sources. On the day of the inspection people, relatives and staff told us that the management team were supportive and approachable.
When we last inspected The Old Vicarage Residential Home in November 2014 a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 were identified. At this inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.