This comprehensive inspection took place on the 17, 18 and 30 October 2018 and was unannounced.

The Old Vicarage Nursing and Residential Care Centre provides nursing and personal care for up to 60 people. The home has two units, each providing nursing and personal care, the Willows unit is specifically, for people living with dementia. On the day of the inspection 57 people were living at the service. Accommodation is provided on two floors, with lounges available on both floors. The dining areas are on the ground floor. There is also a conservatory and a large garden at the back and a small car park at the front.

The service has a registered manager in post who had worked at the home for three and a half 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. Prior to this inspection we received feedback from the local authority contract monitoring team, who said that the home had been subject to an improvement plan that they were in the process of reviewing.

Everyone we spoke with told us that the service was good. Some areas needed oversight and improvements with the management of paperwork.

People were protected from potential harm and abuse by trained staff who were knowledgeable of local safeguarding procedures. Risks to people’s safety were identified and where necessary, appropriate action taken to keep people safe. There were systems in place to help make sure staff employed at the home were suitable to work with vulnerable people.

Staff supported people to take their medicines safely and as prescribed.

People were supported by a team of staff that had had training and support to maintain their skills and knowledge to meet the needs of the people they supported.

People were treated with respect, consideration and kindness. Their privacy and dignity was upheld and they were supported to maintain their independence whenever possible. People receiving support and their relatives offered lots of positive comments about the care provided.

Care was provided in a personalised way from staff who knew people’s needs and preferences. People were involved in the planning and review of their care and support.

The home employed an activity organiser who engaged people in activities in small groups and individually during the day.

Information and arrangements were in place for the staff team to respond to concerns or complaints from people using the service and their representatives.

People who used the service who we spoke with and their relatives all had a positive attitude about the service being delivered and about the standard of care and support provided by the staff team. People were referred to appropriate health and social care professionals when necessary to ensure they received treatment and support for their specific needs.

Stakeholders and members of multidisciplinary teams shared positive feedback about the care provided to people living at the service.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrict way possible. Staff had followed the Code of Practice in relation to the Mental Capacity Act 2005 (MCA).

The inspection took place on the 3 October 2016 over 9 hours and was unannounced. The service had met all of the regulations we inspected against at our last inspection on 28 July 2014.

The Old Vicarage Nursing and Residential Care Centre provides nursing and personal care for up to 60 people. The home has two units, each providing nursing and personal care, but the Willows unit is specifically for people living with dementia. On the day of the inspection 59 people were living at the service.

Accommodation is provided on two floors, with lounges available on both floors. A passenger lift and stairs provide access to the first floor. The dining areas are on the ground floor. There is also a conservatory and a large garden at the back and a small car park at the front. Assisted bathing facilities are provided.

The service had a registered manager in post who had worked at the home for about a year and a half. 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.

Prior to this inspection we received feedback from the local authority contract monitoring team, who said that the home had been subject to an improvement plan but the actions required were almost completed.

We found that the service provided good care and support to people enabling them to live fulfilling and meaningful lives. People that were able to talk to us said they were happy in the home and with the people they lived with. The interactions we observed between people and staff were positive.

People told us they felt safe living at the home, staff were kind and compassionate and the care they received was good. Comments included: “The staff are quite good, you can have a laugh with them”; “They look after us with care in their hearts”; “They’re fantastic”.

The staff ensured people’s privacy and dignity were respected. We saw that bedroom doors were always kept closed when people were being supported with personal care.

People remarked that the food was good and there was plenty of it. One person said, “The food and the catering here is really good, they are very generous”.

People could choose how to spend their day and they took part in activities in the home and the community. The home employed activity organisers who engaged people in activities in small groups and individually during the day. They also took people out in the local community and a minibus was available to take people out on day trips.

People’s needs were assessed and care plans were developed to identify what care and support people required.

People's health and well-being needs were well monitored. There were regular reviews of people’s health and staff responded promptly to any concerns. People were referred to appropriate health and social care professionals when necessary to ensure they received treatment and support for their specific needs.

Staff received specific training to meet the needs of people using the service and received support from the management team to develop their skills. Staff had also received training in how to recognise and report abuse. All were clear about how to report any concerns. Staff spoken with were confident that any allegations made would be fully investigated to ensure people were protected.

People knew who to speak to if they wanted to raise a concern and there were processes in place for responding to complaints.

Some people who used the service did not have the ability to make decisions about some aspects of their care and support. Staff had an understanding of the systems in place to protect people who could not make decisions and followed the legal requirements outlined in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).

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We completed an inspection in July/August 2014 for this service and found all areas we looked at to be fully compliant.

We inspected the Old Vicarage Nursing and Residential Care Centre on 29 September 2014 in response to information of concerns from the local infection control team and Warrington Borough council.

This was an unannounced inspection. The inspection set out to answer two of the five questions we always ask:

• Is the service safe?

• Is the service well led?

Below is a summary of what we found. The summary is based on speaking to the manager and by walking around the home and looking at areas of cleanliness. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

During the visit we walked round the building and looked at all bathrooms, the majority of bedrooms, main lounges and dining rooms. All areas looked clean and tidy and there were no unpleasant odours.

We saw that the home had domestic staff on duty and that the home smelt fresh and clean.

Is the service well led?

We looked at the audits that had taken place for the end of August and September for cleanliness of the home and medication management.

We saw that areas of concern had been identified with regard to cleaning schedules and the manager was taking action to rectify this.

Whilst we were at the home we checked to see how the manager was responding to concerns raised by the local authority about how medicines were managed. The manager told us they were intending to change their pharmacy supplier in October 2014. A pharmacist inspector from the Care Quality Commission will carry out a focussed inspection to assess how medicines are managed when the new system is in place.

When we visited in February 2013 we found the service to be non compliant in two areas. The purpose of this inspection was for us to see what improvements had been made by the provider.

During this visit we saw that improvements had been made in the identified areas and that work was still ongoing. There was a relaxed atmosphere within the home that was clean and there were no offensive odours.

Since the previous inspection the manager and the activities co ordinator have left employment and the provider is currently recruiting to these positions.

We saw that people were being supported by staff at mealtimes in an appropriate way and that the food appeared appetising and was plentiful. However, although we saw a planned menu rota for several weeks people living at the service were unable to say what food was available on the menu as their choice was only provided verbally.

One person living at the service told us that ''everyone goes out of their way to help '' and ''all of the staff are very good and caring and towards the people who are most vulnerable.''

A relative told us that they were always made welcome and there were no problems with the care provided. However there was a problem with personal possessions being lost or misused and with the cups that were used being too big or difficult for some people to manage.

When we inspected The Old Vicarage previously in January 2014 we found that we found that improvements were needed to protect people from receiving inappropriate or unsafe care.

Following our inspection in January 2014 the provider sent to us an action plan. This showed us that the provider was aware as to what needed to be done and was committed to ensuring that the people who lived at the home received safe and appropriate care that met their needs and protected their rights.

The home had been subject to monitoring visits by Warrington Borough Council following safeguarding issues reported by the home and whistle blowing concerns reported to Care Quality Commission.

The home had provided an action plan to Warrington Borough Council to address issues raised.

Visits had been made by the Infection Control team to ensure that the home was clean and free from infection. At the last visit on 6 August the score for the cleanliness at the home had deteriorated.

Notwithstanding the above we considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. The summary is based on our observations, including SOFI during the inspection, speaking with people using the service, their relatives; the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

• Is the service safe?

The manager advised us that appropriate procedures, including review were in place should anyone need to be subject to a Deprivation of Liberty Safeguard (DoLS). DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. Some of the staff we spoke with were not fully aware of Mental Capacity Act and DoLS.

We spoke with the registered manager who told us they were aware of the shortfalls in training and had booked training sessions. They told us they were currently reviewing all training at the home and were planning the training for the coming year. This training included the Mental Capacity Act and DoLS.

Is the service effective?

We saw that care plans had been written based on the information provided in the assessment documents. Care plans were comprehensive and provided a good picture of the person, their needs and how these were to be met. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

During our inspection we found that the people living at The Old Vicarage looked well cared for and were dressed appropriately for the weather on the day. People were clean and tidy and their hair had been brushed or combed.

Is the service caring?

We saw that staff interacted well with the people who lived at the home. The atmosphere in the home felt relaxed and sociable. We saw that staff spoke to people who used the service when they were passing them in corridors or in the lounges. Relationships were warm and respectful.

Staff spoken with were knowledgeable about the people they cared for.

People we spoke with said "I like it here. Staff are really nice," " I can't fault the staff, the whole place is great" and "yes it's ok the food is good."

Relatives told us " the home is improving all the time. They look after my relative well." and " the staff and managers are always pleasant. I know my relative is looked after."

Is the service responsive?

At our last visit in January we issued compliance actions in two outcomes we looked at . The provider had produced an action plan and at this visit we found that these actions had been met.

We looked at the care plans and found that referrals were made and recorded when people had needed professional support such as GPs district nurses, tissue viability, dieticians and mental health teams.

We saw that the service had been visited by the infection control team and Warrington Borough Council’s monitoring team. The registered manager had completed action plans and liaised with these external teams to improve the care people received at the home.

Is the service well led?

The Old Vicarage had systems in place to gather information about the safety and quality of the service provided. This included audits of areas such as care plans, medication, accidents, falls, the environment and the kitchen. If there were any issues identified following an audit these would then be dealt with. We saw examples of action plans completed and signed by the manager.

A survey had been sent out to relatives in July and comments such as “found the registered manager to be pleasant and professional and feel she would listen to my concerns,” “staff are pleasant and treat my relative very nicely” and “ happy atmosphere” were made.