The inspection took place on 14 December 2017 and was unannounced.

At the last inspection in November 2016 we rated the service as Requires Improvement. At this inspection we have changed this rating to Good.

The Vicarage Nursing Home provides nursing care to up to 52 older people, most of whom are living with dementia. At the time of our inspection, 36 people lived at the home.

The Vicarage Nursing 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.

People’s bedrooms are on the ground and first floors and these are accessed by stairs or a passenger lift. People have access to communal areas within the home and access to the home’s gardens.

No registered manager was in post. The last registered manager had deregistered with us but was now continuing at the home. They had re applied to be registered with us and their application was being assessed at the time of our inspection. They were present during our inspection. 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.

Staff had received training in and understood how to protect people from any harm and abuse. Systems were in place for staff to follow which protected people and kept them safe. Staff knew how to and were confident in reporting any concerns they may have about a person’s safety.

Risks to people were assessed and kept under review, and staff acted to manage identified risks safely.

Medicines were managed, administered and stored safely. There were systems in place to ensure people were protected from the risk of infection. Accidents and incidents were recorded and acted on appropriately.

People were supported by sufficient numbers of staff to safely meet their needs. Although some agency staff had been used recently, they understood how to support people safely. Checks were completed on potential new staff to make sure they were suitable to work with people living at the home. New staff were waiting for these checks to be completed before they commenced work at the home.

People’s needs and choices were assessed. Staff had the skills and knowledge to understand and support people's individual needs and support them effectively. These skills were kept up to date through regular training and staff were also supported in their roles by managers and their colleagues.

People’s consent was sought by staff before they helped them with any care or support. People’s right to make their own decisions about their own care and treatment was supported by staff. Where people were unable to make their own decisions these were made lawfully and in their best interests.

People's nutritional needs and preferences were met. Staff worked with other health and social care professionals as required to deliver effective care and support to people.

People were supported by staff who knew them well and had good relationships with them. Staff made sure people were involved in their own care and made sure they understood information that was given to them. People were treated with dignity and respect.

People received care and support that was responsive to their individual needs. People were encouraged by staff to express their views, preferences and wishes in regard to their care, support and treatment. Pathways were in place to help ensure people received appropriate support at the end of their life.

People and their relatives knew how to raise concerns or complaints. They were comfortable to do so and felt staff and managers listened to them and took action as needed.

The improvements to t

This inspection took place on 7 and 9 November 2016 and was unannounced.

The Vicarage Nursing Home provides accommodation with nursing and personal care to a maximum of 52 people. There were 35 people living at the home on the day of our inspection.

There was no registered manager in post at the time of our inspection. The service is required to have a registered manager. During our inspection, we met with the home manager who had applied to become registered manager of 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 2008 and associated Regulations about how the service is run.

At our last inspection on 24 February 2016, we found breaches of Regulations of the Health and Social Care 2008 (Regulated Activities) 2014. We gave the service an overall rating of inadequate. These breaches related to the provider's failure to respect people’s dignity, provide safe care and treatment, ensure good governance, maintain sufficient staffing levels and display the service's most recent performance rating on their website. The home was placed into special measures, meaning significant improvements were required or further enforcement action could be taken. The provider sent us an action plan setting out the improvements they intended to make.

At this inspection, we found the provider had made significant improvements to the service. However, people still did not always receive safe support from staff to move. Staff also lacked understanding of how to protect people’s rights under the Mental Capacity Act 2005. They were also unclear about the purpose and status of any Deprivation of Liberty Safeguards (DoLS) authorisations granted for people living at the home.

Staff understood how to recognise and report abuse. The provider had developed procedures to ensure any concerns about abuse were passed on to the relevant external authorities and investigated. The risks associated with people’s care and support needs had been assessed, monitored and plans put in place to manage these. The provider had assessed and organised their staffing requirements in order to safely meet people’s care needs. People’s medicines were safely managed by the provider.

Staff received ongoing management support to carry out their duties and responsibilities effectively. People had the support they needed to eat and drink safely and comfortably. Their nutritional needs and dietary requirements had been assessed and addressed. People were supported to access healthcare services. Staff played an active role in monitoring people’s health and sought prompt professional medical advice and treatment when necessary.

Staff took a caring and compassionate approach towards their work. The involvement of people and their relatives in decision-making was encouraged by the provider. Staff treated people with dignity and respect.

People received personalised care that took into account their needs, interests and preferences. People’s relatives knew how to complain about the service. The provider had developed a formal procedure to ensure complaints were dealt with appropriately.

The manager promoted an open and inclusive culture within the service. They provided effective leadership and management of the service. The provider made use of quality assurance systems to assess, monitor and make improvements to the quality of the service.

This inspection took place on 24, 25 and 26 February 2016 and was unannounced.

The home was last inspected on 20 October 2015 where we gave it an overall rating of requires improvement. We had identified the provider was in breach of Regulations 12, 17 and 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches related to staff not always supporting people to move safely, a lack of effective quality assurance procedures and failure to display their ratings from our previous inspection. We asked the provider to make improvements and send us their action plan by 17 February 2016. We did not receive this action plan prior to this inspection. We found that little improvement had been made since our last inspection.

The Vicarage Nursing Home is a specialist dementia nursing home. It is registered to provide accommodation with nursing and personal care to a maximum of 52 people. There were 37 people living at the home on the day of our inspection.

There was no registered manager in post. The service is required to have a registered manager in post. The home had a manager who was present during our inspection. 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 were not always cared for by sufficient numbers of staff. Agency staff were used to cover the shortfalls in staffing but they did not always know what people’s needs were. This was because they were not always provided with or had access to this information. Relatives had concerns because this meant there was not always a consistency in people’s care and support.

People were placed at risk of harm because staff did not always know the risks that were associated with their care and support. Agency staff were not always provided with information that would help them keep people and others safe within the home. Medicines were not always managed safely.

People who were cared for in their bedrooms did not have call bells placed within their reach and had to shout for assistance. Because staff were busy in other areas of the home people’s shouts for assistance were not always heard by staff. This placed people at risk of harm because staff could not always meet their needs in a timely manner.

The provider offered specialist dementia care but staff were not clear on how they were to meet people’s dementia care needs. Staff were not supported by the provider to carry out their roles effectively. Staff did not have one to one support that would have enabled them to raise concerns and identify training they needed to meet people’s needs.

People and relatives liked the staff who cared for them; however they felt the inconsistency of agency staff made it difficult for staff to understand their care needs.

Staff knew what specialised diets people needed, although the information relating to people’s eating and drinking was not always kept up to date. Staff did not always keep accurate records to show what people ate and drank each day when this was needed. This placed people at an increased risk to their health and wellbeing.

Staff were not able to always ensure people’s dignity because they were sometimes too busy to support people when they needed it. Staff knew the care they provided was task focused and not always individual to each person but felt too rushed to be able to give people the time they needed.

There was little accountability within the home and staff were not clear on their own and other staff’s responsibilities. No processes were used to assess and monitor the quality of care provided and no one took responsibility for ensuring tasks were completed by staff. Staff and managers who were aware of shortfalls within the home h

This inspection took place on 20 October 2015 and was unannounced.

The Vicarage Nursing Home is registered to provide accommodation with nursing and personal care to a maximum of 52 people living with dementia.

A registered manager was 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.

The home was last inspected on 8 December 2014 where we gave it an overall rating of requires improvement. We asked the provider to take action to make improvements to how they obtained people’s consent. This was to make sure people’s rights were protected when they could not make their own decisions. The registered manager sent us an action plan and told us they would complete these actions by the end of June 2015. We invited the registered persons to send us an update to their action plan and we also asked them to inform us when they had completed the actions which they did not do. At this inspection we found that improvement had been made. This was because the registered manager had worked with other professionals to make sure people’s rights were protected when they could not consent to their own care and treatment.

At our last inspection we made a recommendation that the provider seek guidance on dementia care environments which they have done. We also had concerns because some staff used unsafe moving and handling practices. Some staff were not trained to support people with dementia and staff did not always involve people in making choices about their day to day care. We also had concerns that people did not receive much social interaction. We found improvement had been made in most of these areas of concern.

The provider had put resources and support in place to help drive improvement following our last inspection. However, the registered manager did not fully understand their regulatory responsibilities and had not made all the improvements they had told us they would make in the action plan they sent to us. Not all staff were supported by managers and did not feel their opinions mattered.

Managers at the home did not take full responsibility for making decisions about people’s capacity and relied on other healthcare professionals to make sure this was done in their best interests. Some people had lawful restrictions authorised but staff were not always aware why these were in place and what they meant for people. Decisions that had been made on behalf of people were not always recorded to show why they were in their best interest.

The registered persons are required to display their inspection ratings conspicuously at the home and on their website. Ratings we awarded the home following our last inspection had not been displayed at the home or on their website.

People were still placed at risk of harm by staff who sometimes used unsafe moving and handling practices.

Sufficient staff were working on the day of inspection however; some relatives and staff thought that sometimes there were not enough staff.

Not all staff had received dementia training or knew that this had been booked for them. Some staff had not received regular supervisions and were not clear what approach to dementia care they should use. Some staff felt overburdened with their workload because they were supporting new staff and agency staff.

Staff had been trained to recognise abuse and knew the procedure they must follow if they suspected abuse. Risks to people were identified and monitored by staff. People received their medicines safely from staff who were trained to support them.

People enjoyed their meals and were able to choose what they ate and drank. Healthcare professionals were involved and consulted when there were concerns with people’s health.

People were treated with dignity by staff and their privacy was respected. Staff supported people to be involved in day to day choices about their care. Staff understood people’s personalities and behaviours and were able to respond in a caring way when people became anxious.

People were able to orientate themselves within the home and engage with conversational and reminiscence prompts throughout the downstairs of the home. People were supported to take part in individual and group activities which reflected their hobbies and interests.

The provider involved relatives and staff in what was happening at the home and improvements that had been made.

You can see what action we told the provider to take at the back of the full version of the report.

This inspection focused on the management of nutrition and hydration for people who were living with dementia. We conducted a short period of observation whilst people were supported to eat their lunch. This was because not all people were able to tell us their views.

People who lacked ability to manage their own meals received good support and were referred to specialist advisors as necessary. People's nutritional health needs were closely monitored by the staff and visiting health professionals. Staff we spoke with were aware of information about cultural and religious requirements as well as individual food preferences.

We saw that people living with dementia were given help and assistance with their nutritional and hydration care needs. Staff demonstrated a good understanding and knowledge of the individual dietary and fluid intake needs of the people in their care.

Care records were in place and provided staff with instructions on how people should be encouraged to eat and why. We found record keeping in place regarding the monitoring of fluid and food intake.

The home had sufficient staff to ensure people's safety and wellbeing regarding nutritional management. The provider had systems in place to assess and monitor the quality of the service provided regarding nutrition and hydration. A monthly overview of the management of the service was in place. This meant that the service was well led.

We spoke with six staff, the manager and a member of the senior management team. We also spoke with two healthcare professionals. People who lived at the home were not able to tell us their views. This was because they had communication difficulties. There were 36 people living in the home on the day of the inspection.

There had been improvements in the way that people received care and support since our last visit in October 2012. Some care plans contained contradictory information and some people did not receive the care they needed.

The service provided a choice of nutritious food that met people's dietary needs. People were offered appropriate support and mealtimes took place in a pleasant dining room and atmosphere.

The home was clean and tidy. Measures were in place to reduce the risk of healthcare associated infections.

The majority of people were not able to tell us about their experience of living at The Vicarage. We spoke with three relatives, the manager, the operations manager and six staff.

People and their relatives were generally satisfied with the service provided.

People did not receive the care and support they needed to maintain their well being and spend time with other people.

Staff were seen to be patient and kind towards people.

People were provided with nutritious meals that met their dietary needs. Mealtimes were chaotic and people were not given the support they needed to eat and drink.

Measures were not in place to protect people from the risk of healthcare associated infections.

The home was adequately maintained and people were able to personalise their own rooms.

Checks were made before staff started working at the home to make sure they were suitable.

There were systems in place to monitor and review people’s complaints.

People had stated that they were consulted about the care of their relative, that their views were taken into account in the way the service was provided and delivered. They had commented that their privacy and dignity was respected and their independence promoted.

People said that they wouldn’t hesitate to ask questions or request help with any aspect of their relatives’ care.

This inspection took place on 8 and 9 December 2014 and was unannounced. At our previous inspection no improvements were identified as needed.

The Vicarage Nursing Home provides accommodation with personal and nursing care for up to 52 people living with dementia. At the time of our inspection 46 people were living at the home.

The home had a registered manager post who was present for our inspection. 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’s rights were not being protected when they could not consent to their own care or make their own decisions about their own care. When consent had been given by relatives there were no records to say why the person could not make their own decision and why decisions made for them were in their best interests.

We have made a recommendation about the provider seeking guidance on dementia care environments.

Staff had identified and understood the risks associated with people’s care. These included where people were at risk of falls, not eating or drinking enough or problems with their skin. We found that although staff were aware of these risks people’s care records did not always reflect actions staff were taking to reduce the risks.

Training that staff received was not always effective in safely meeting people’s needs. Not all staff had received training that would help them to support and understand people living with dementia.

People had been assessed as to whether they were at risk of not eating and drinking enough. Although these risks were monitored there was not always clear information in their care records as to how this was being done. People had access to healthcare when they needed it.

People were not always actively involved and supported to express their choices or views about their care and treatment. The way that staff spoke with people was not always understood and was sometimes disrespectful to them. People were frequently addressed as love, sweetheart, good man and good girl.

Staff had a good knowledge of the people who lived at the home and were able to tell us how people liked to be supported and what their likes and dislikes were. We could not confirm these were accurate as this information was not in people’s care records.

Visitors were made welcome and were able to visit at any time. There were areas of the home where visitors could have privacy with their family members and this was respected by staff. Relatives felt involved in and kept up to date about their family member’s care.

The provider sought the opinions of relatives and staff and used this to help improve the home. Relatives’ meetings were held regularly and concerns raised were dealt with. Staff felt supported in their roles and felt confident to report any concerns they had to the management.

Quality assurance processes had identified some areas for improvement and action was in progress to address these. However, we did find some issues during our inspection which the provider and registered manager had not identified.

You can see what action we told the provider to take at the back of the full version of the report.