The Old Vicarage is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The Old Vicarage accommodates 38 people in one adapted building. At the time of the inspection there were 36 living at The Old Vicarage.

The service had 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.

At the last inspection carried out in December 2017 we found two breaches of regulations. Following the inspection the provider sent us an action plan telling us how they would address the breaches. At this inspection we found the actions taken had addressed the breaches and there were no new breaches.

We found systems and processes in place to keep people safe. These included ensuring risk assessments had been carried out to mitigate risk. Medicines were stored and administered as prescribed. Accidents and incidents were recorded and investigated and where possible actions were taken to ensure people’s safety. Staff were aware of their duty of care to protect people from abuse and were trained to recognise the signs of abuse. Risk of infection was mitigated as the provider had systems in place to ensure the premises were clean and fresh and staff had access to protective clothing.

There was sufficient numbers of appropriately recruited and trained staff to meet people’s needs and wishes. People had a pre-admission assessment to ensure the service could meet their needs. A care plan detailing their needs was drawn up and reviewed with the person or their relative where possible. This was done on a regular basis. The care plan gave staff clear directions on how to care for people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.’

People’s nutrition was promoted by ensuring fresh nutritious food was available and by referring people who had difficulty in eating to the appropriate health care professions.

People’s physical and mental health was promoted by working closely with health and social care professionals.

Care was delivered by staff who were caring, kind and compassionate. Independence was promoted and people had a variety of ways of making their needs and wishes known to the manager and staff. This included regular meetings.

Care was personalised and responsive to individual needs and wishes. There was a complaints process in place and people knew how to use it. The service received many complements on the service they offered.

The service was well led. The registered manager had a quality monitoring system in place. Aspects of the service such as risk to people, administering medicines and staff training were regularly reviewed. People told us the registered manager was approachable and easy to talk to.

This inspection took place on 27 November and 5 December 2017; the first day was unannounced.

At our previous inspection in July 2016; the service was rated as 'Good' overall. At this inspection the service was rated 'Requires Improvement' overall. This is the first time the service has been rated 'Requires Improvement'.

The Old Vicarage is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The Old Vicarage accommodates up to 30 people in one adapted building. At the time of our inspection 27 people lived at The Old Vicarage; one of these people had been admitted to hospital.

The service is required to have 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. At the time of our inspection there was a registered manager in post who was present during our inspection.

Evidence that actions had been taken to help reduce and manage known risks to people's health was not always available. Actions to reduce known risks in the environment and to help prevent and control infection were not always followed. Not all accidents and incidents were reported in line with the registered manager's expectations. Systems had not always been followed to ensure safeguarding referrals were made when allegations of abuse had been made. Systems and processes designed to assess, monitor and mitigate risks were not always followed. Required improvements had been identified as needed, however the required actions had not always been implemented.

Changes in people's levels of care needs had not always been referred to other organisations in a timely manner. Advice from other healthcare services had not always been clearly reflected in care plans and risk assessments. Not all staff were mindful of people's privacy and showed them sufficient consideration.

Records were not always accurate, complete or made contemporaneously. Records did not always demonstrate people received personalised and responsive care in line with their care plan. Sufficient numbers of staff were available, however we did not receive assurances suitable numbers of staff had been trained to competently use the fire evacuation equipment in the home.

People's communication and information needs were assessed; however one member of staff had not received the information and communication support they required.

People told us they felt safe and had not experienced discrimination. Procedures were in place to prevent discrimination and the principles of the MCA were followed; information was accessible to people. Adaptions to the premises ensured it was suitable for people.

Medicines were managed safely. People received sufficient to eat and drink.

Staff were supported to develop skills and knowledge through training. Most people told us staff were kind and care staff spoke respectfully about people. People's independence and dignity was respected. People and families were involved in decisions about their care. People and families contributed to care plans. Processes were in place to provide support and care for people who were approaching the end of their lives.

The provider had clear values and aimed to provide good quality care where people could provide feedback. A registered manager was in place, and people found the registered manager approachable. Supervision processes were in place to support staff and the provider operated other systems to ensure staff were rewarded and valued.

At this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activiti

The inspection took place on 28 July 2016 and was unannounced.

The Old Vicarage is registered to provide accommodation for people up to 38 who require nursing or personal care including people who are living with dementia. At the time of the inspection there were 26 people living at the service.

On the day of our inspection there was a registered manager in place. 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 that they felt safe. The risk of harm for people was reduced because staff knew how to recognise and report any incidents of harm. Staff were confident that the registered managers would deal with any concerns that they reported.

Medicines were safely administered and stored.

Staffing levels were adequate to meet people’s needs. Staff were recruited through safe recruitment practices. Staff received an induction, training and supervision.

People had access to external healthcare services.

Staff were trained in the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and could describe how people were supported to make decisions.

People received sufficient to eat and drink and had a choice of meals.

Staff did not always respect people’s privacy and dignity.

People told us staff were kind and caring. Staff were aware of people's support needs and their personal preferences. People and/or their relatives were involved in the development and review of their care plans. People were encouraged to be independent.

People had the opportunity to take part in a variety of activities inside the service. Daily records were up to date and gave a good overview of what had occurred for that person. Complaints were dealt with in a timely manner.

The registered manager was supportive, approachable and listened to people, relatives, external professionals and staff. People and their relatives were involved or had opportunities to be involved in the development of the service. There were systems in place to monitor and improve the quality of the service provided.

A single inspector carried out this inspection. We talked to five people using the service and one person’s relative. We looked at four people’s care records and observed care being provided. We talked with two staff, the manager and regional manager. We examined training records and the documentation relating to quality audits.

This helped us to answer the questions below.

Is the service safe?

Systems were in place to record incidents and accidents and to learn from these This reduces the risks to people and helps the service to improve.

People were treated with dignity and respect by the staff. Staff were provided with training to enable them to identify the signs of possible abuse and how to safeguard the people they cared for. They knew how to raise concerns and were confident that if they reported concerns, they would be acted on.

Individual risk assessments had been carried out for the people using the service and care was planned in response to these. This meant care and support was planned in a way that was intended to ensure people’s safety and welfare.

Systems were in place to maintain safe staffing levels and take account of fluctuations in requirements. This helped to ensure people’s needs were met.

Is the service effective?

Full assessments of each person’s care and support needs were undertaken. Care plans were reviewed regularly and updated as necessary to ensure the support provided was appropriate to each person’s individual needs.

We saw there was involvement of a range of professionals in each person’s care, ensuring care was effective and specialist input obtained where necessary.

There was a structured approach to training to ensure staff maintained the skills and knowledge required to provide effective and appropriate care.

Is the service caring?

The staff knew the people who used the service well and had positive relationships with them. They were attentive to people’s needs and gave them encouragement and support. The people we talked with, told us staff listened to them and responded to their needs and wishes.

People told us staff regularly talked with them and discussed their care and well- being. If they raised any issues they were addressed.

Is the service responsive?

Staff were able to recognise signs of ill health and seek specialist input and advice where necessary. Action was taken promptly when a person’s health deteriorated and the emergency services called.

The service sought feedback on the care provided and acted on the information it received. Systems were in place to record concerns and the actions taken to improve.

A range of activities were provided for the people using the service according to their wishes.

Is the service well led?

Quality review systems were in place to monitor and assess the quality of the service. Records showed that quality audits had been carried out regularly. Issues for improvement identified from the audits had been brought together and the resulting action plan was monitored to ensure improvements were made. This meant that information gained from audits was used to improve the service.

Staff received regular supervision and appraisal. They told us they felt well supported by the manager and encouraged to undertake further development.

The manager was visible on the floor and accessible to the people using the service. They expressed confidence that if they raised an issue it would be addressed.

When we visited on 1 July 2013, we found that people were unable to benefit from some essential equipment that had not been properly maintained. We asked the provider to take action to ensure equipment was always available to meet people's needs.

We visited again to make sure appropriate equipment was available and being used safely. We checked the equipment and observed staff using a hoist. We found that staff were well aware of the procedures to use the equipment safely. However, a stand aid hoist was not available at that time and meant that some people were dependent on being fully lifted.

We had contact with the provider's regional manager and one week following our visit we received confirmation that a new stand aid hoist was at the home and available for use. This meant there was enough equipment to promote the independence and comfort of people who used the service.

There were procedures for monitoring that equipment was maintained correctly. The regional manager has assured us, "Any equipment found to be faulty will be repaired or decommissioned and a replacement provided."

The last time we visited, we found some peoples' needs were not fully met, because care plans did not always provide the details needed for staff to know what care they should provide. We visited on this occasion to review the improvements made and consider some other areas of the service.

As part of the inspection we spoke with five people who used the service and two visiting relatives. We also observed the care staff were giving and looked at some records.

We found that the care plans were more specific than we saw during our previous visit and gave staff the information they needed to deliver care in a way that was intended to ensure people’s safety and welfare. One person told us, "They (the staff) are marvellous. Most of them know exactly what I need especially (names given of the senior staff)." Another person said, "I think I have what I need here - they get it right for me."

We found that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. One person told us, "They always bring my tablets when I'm having my breakfast and they make sure I take them."

We were concerned that some equipment was in need of repair or replacement and this meant that people had to wait a while for a hoist to be available before they could be moved.

We found that people were cared for by staff who had been carefully recruited and this meant they were in safe hands.

Prior to our visit we reviewed all the information we had received from the provider. During the visit we spoke with twelve people who used the service and asked them for their views. We also spoke with five care workers, the activities coordinator, the deputy manager and the regional manager. We also looked at some of the records held in the service including the care files for four people. We observed the support people who used the service received from staff and carried out a brief tour of the building.

We found people were respected and involved. A person who used the service told us, “If you say, could I have it done this way or that way, they will do it as you ask. Maybe they could ask a bit more first.”

We found people were happy but they did not always receive care and support that met their needs. A person told us, “We are well looked after. The staff are very, very nice and helpful.”

We found the premises were kept clean and there were infection control procedures in place

We found people were safeguarded from abuse. One person said, “I’ve not met any staff that are not nice to us.”

We found the staff team were supported through training. A person told us “Their job is to look after us and that is what they do.”

We found the provider assessed and monitored the quality of the service. A person told us, “I think we should be able to offer an opinion on things.”