About the service: The Old Vicarage Residential Home is a residential care home that was providing personal care to 13 people aged 65 and over at the time of the inspection.

People’s experience of using this service: People were not kept safe because all their risks were not assessed and planned for and their medicines were not safely managed. These were continued issues from the last inspection. Not enough improvements had been made since the last inspection to ensure people received a safe and good quality service.

There were not enough staff to safely meet people’s needs. The provider acted to increase staffing levels following our feedback but they had not identified this issue for themselves.

The providers systems to monitor and improve the quality and safety of the service were still not effective. Lessons had not always been learned when things had gone wrong.

People’s choices and preferences were not always respected because there were not enough staff on duty to facilitate people’s choice. People were not always involved in their care planning so did not have the opportunity to voice their preferences.

Improvements had been made to ensure people consented to their care.

People enjoyed the food on offer and had choices of meals. People were happy with the way staff treated them.

There was a new manager since the last inspection and they were in the process of registering with CQC. People knew the manger and staff felt supported.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection: At the last inspection the service was rated Inadequate. The report was published 14 September 2018 and the supplementary report (including enforcement action taken) was published 1 December 2018.

Why we inspected: This was a planned inspection based on the previous rating.

Enforcement: Full information about CQC’s regulatory response to the more serious concerns found in inspections is added to reports after any representations and appeals have been concluded.

Follow up: The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

This inspection took place on 30 and 31 July 2018 and was unannounced.

The Old Vicarage Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or 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. Care and support is provided in one building with a communal lounge and dining room. The Old Vicarage Residential Home is registered to provide care and support for up to 15 people. At the time of this inspection 15 people were using the service.

There was a registered manager. 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.

This was the first inspection since this service was registered on 25 February 2017. The home was rated ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Risks to people's safety, health and wellbeing were not always suitably assessed and managed.

There was not always enough suitably skilled staff deployed at night time to administer medicines to people if this was required. Staff were not always trained to provide safe and effective care.

People were not always protected from the risks of avoidable harm and abuse because incidents of possible abuse were not always identified and reported to the local authority as required. Action was not always taken to protect people from further occurrences.

We found that medicines were not managed safely and people were at risk of not receiving their medicines as directed by the prescriber.

Safe recruitment processes were not always followed when employing new staff members and volunteers.

Systems in place to consistently assess and monitor risks to people and the quality of care provided were not operated effectively. This meant that issues with the safety and quality of the care were not reliably identified and rectified.

People were not supported to have maximum choice and control of their lives and staff do not support them in the least restrictive way possible.

People did not always receive an apology when things had gone wrong.

We were not always notified of events that are required by law.

Pe