This inspection took place on 27 and 28 March 2018. Due to unforeseen circumstances the draft report had not been written when we received concerns in May 2018, therefore a further visit was carried out on 22 May 2018.

At the last inspection we found Vicarage House Nursing Home required improvement and breaches of the regulations resulted in four requirements. These identified that people were not always treated with dignity and their independence was not always promoted. The service did not always follow a best interest process when people were unable to consent to care and treatment. The service did not have effective systems in place to assess monitor and improve the quality of care provided.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the service provided.

At this inspection we found there had been an improvement in the quality of care provided however the systems in place were new, the new manager had only been in post for three weeks. Therefore Vicarage House Nursing Home continues to be rated requires improvement so that the improvements in place can be seen to be consistently effective.

Vicarage House Nursing Home 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 home is registered to provide personal care and accommodation to up to 32 people who are frail or living with dementia. Accommodation is provided in a converted residential dwelling over two floors. At the time of our inspection 27 people were using the service.

There was no registered manager in post however the new manager was in the process or applying to be registered with the Care Quality Commission. 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.

There were processes and practices in place to keep people safe. People told us they felt safe living in Vicarage House Nursing Home and with the staff who supported them. However some relatives said they were concerned about the number of new managers recently and were, “Keeping an eye on the changes to ensure their family member remained safe”.

There were systems in place to ensure the management and administration of medicines was safe and protected people from harm. The provider’s recruitment policy protected people from possible harm from the employment of inappropriate staff.

People received effective care and support because staff understood their personal needs and abilities. Staff had the skills and knowledge to meet people’s needs. The provider had a programme of training which ensured staff had up-to-date guidance and information. The new manager explained they had also introduced other training which was specific to the needs of people living in the home.

People told us they were always consulted fully before any care and support was carried out. Staff were supported to develop their skills through training, staff meetings and one-to-one conversations. The new manager told us, and all staff spoken with confirmed, that they had carried out one-to-one meetings with all members of staff. This meant they had identified areas for training and development and areas of interest for staff to be involved in in the future.

Most of the people spoken with said they received care and support from staff who were polite and kind. One person said, “The staff are always very caring and very polite”. However another person told us that about 10 months ago they did not feel a member of staff was very caring or polite towards them. They con

Vicarage House Nursing Home is registered to provide accommodation, nursing and personal care support for up to 32 older people. At the time of this inspection there were 30 people living there. This inspection was unannounced and took place on 29 November 2016.

The last comprehensive inspection of the home was carried out on 30 September and 05 October 2015. At that time there was a new manager in post who had not yet been registered. There had previously been breaches of regulation concerning record keeping relating to people's care, recruitment, and quality assurance. We found the new manager had implemented changes which had improved these and other aspects of the service, however they needed to prove these changes could be consistently maintained. Although we found no breaches of regulation at the inspection on 30 September and 05 October 2015, the home was rated ‘Requires Improvement’ because we identified further concerns about staff training and the involvement of people in the day to day running of the home.

We carried out an additional focussed inspection on 21 April 2016 to look at safeguarding concerns related to a lack of staff training and knowledge in the moving and handling of people, and the failure of staff to respond to people’s changing needs. We found all staff had received training in moving and handling people and were using moving and handling equipment correctly. We also found staff were responsive to the changing needs of people in the home.

At this comprehensive inspection in November 2016 we checked whether improvements had been made since the last comprehensive inspection in September 2015. We found that while some improvements had been made, they were not always effective. We identified additional areas of concern.

There was a risk that people might not receive safe care, because risks to their health and welfare had not always been accurately assessed, recorded or reviewed. This meant staff did not have access to up to date written information about potential risks or the actions they must take to reduce those risks. Care plans did not provide the guidance staff needed to provide safe, effective, personalised care. This lack of information increased the risks for people, particularly if staff were less familiar with the person, for example if a person without the capacity to understand the risks, refused to be supported by care staff, or had communication difficulties due to sensory loss.

The systems in place for the administration of medicines were not safe, which put people at risk. The medicines policy did not cover all the required areas and failed to comply with current legislation and guidance for medicines administration. Medicine Administration Records (MAR) were handwritten, unclear and did not always contain the information needed to administer medicines accurately and safely.

Staff training related to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), needed to improve so that people’s legal rights could be fully protected. Some people had restrictions in place, such as bed rails, but there had been no consideration of whether these restrictions were in their best interests. In addition some ‘blanket’ capacity assessments had been made relating to people’s ability to make decisions, rather than a specific decision, which indicates the MCA was not well understood. We also found people were potentially being deprived of their liberty, but had not been referred for assessment.

During the inspection we found that although some staff were kind and caring when supporting people, the ‘person centred’ values expressed by the registered manager were not consistently put into practice. Much of the care we observed in communal areas was ‘task focussed’, and people and relatives confirmed staff rarely spent time chatting with people in the lounges unless they were taking them to the toilet or giving them their meals. People and relatives told us

This inspection was unannounced and took place on 21 April 2016. We carried out this inspection to check whether people using the service received care that was safe and responsive to their changing needs following safeguarding concerns which were shared with us about the care and support people received at the home.

The last inspection of the home was carried out on 30 September and 05 October 2015. At that time we found some staff training had not been carried out however dates had been booked. People were not always involved in the day to day running of the home. There was no registered manager in post. We found the new manager had implemented changes which they needed to prove they could maintain consistently. This report only covers our findings in relation to the recent safeguarding concerns we received. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Vicarage House Nursing Home on our website at www.cqc.org.uk.

Vicarage House Nursing Home is registered to provide care and accommodation for up to 32 older people. There were 31 people living in the home at the time of the inspection.

There is a registered manager 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.

One concern received before this inspection stated staff had not received training in how to safely move people when they were unable to stand or mobilise and used incorrect and unsafe moving techniques. The concerns also stated staff had not received training in the correct use of equipment provided to lift and move people.

At this inspection we found all staff had received training in moving and handling people. Records showed, and staff confirmed, training had been carried out in the correct procedures to follow and the correct use of moving equipment. During the inspection we observed staff using equipment to lift people who were immobile. We saw they followed the correct procedures and used lifting equipment safely and appropriately.

Before this inspection we also received concerns that the changing needs of people had not been noted and as a result a hospital admission was delayed.

At this inspection we found staff were responsive to the changing needs of people in the home. Records showed people’s needs were assessed and reviewed regularly with referrals being made to health care professionals when necessary. We found people were referred to specialist clinicians and to the hospital if assessed as needed. People’s care plans included advance decisions such as if they wanted to be admitted to hospital if their health deteriorated and if they wished to be resuscitated in the event of a cardiac failure. Staff were also aware people and relatives had the right to change their minds about any advance decision made.

We made an unannounced visit to the service on 29 April 2014. We met people who lived in the home and spoke to staff. We reviewed staff recruitment and quality assurance documentation. There were 30 people living in the home and we met with all of them in communal or private settings. When we inspected the home the home on 13 December 2013 we found improvements were needed in the way staff were recruited. We also asked the home to formalise the quality assurance processes. We had received an action plan dated 30 January 2014 stating the home would be compliant for Regulations 21 and 10. We found at this inspection action had been taken, improvements had been made and the service was meeting the regulations.

Improvements are required to some aspects of record keeping in the home. Records seen did not always reflect the safe and appropriate care we saw or the attention to safe recruitment of staff.

The focus of the inspection was to answer five key questions: Is the service safe, effective, caring, responsive and well led? This was a summary of what we found:

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe. People told us staff answered their bells promptly and came to their assistance during the day and night. One person told us "Of course we feel safe here. We have friends “outside” who visit often. We can talk to matron and there are always nurses on duty."

Systems were in place to make sure managers and staff learnt from events such as accidents, incidents, concerns and investigations. This reduced the risks to people and helped the service to continually improve. The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards which applies in care homes. Nobody in the home was subject to a DOLS order at the time of the inspection. The home had policies in place and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The manager had undertaken training in safeguarding adults and implementing the Mental Capacity Act in 2013.

The service was safe, clean and hygienic. Staff understood how to reduce the risks of infection through routine cleaning and use of thorough hand cleansing. Equipment was well maintained and serviced.

The manager had day to day contact with people in the home. They set the staff rotas and took people's needs into account when making decisions about the numbers, qualifications skills and experience required.

Recruitment practice was safe and thorough although some improvements with record keeping were required. No staff had been subject to a disciplinary action. Policies and procedures were in place to make sure unsafe practice was identified and people were protected.

Is the service effective?

People's health and care needs were assessed with them, and they were involved in compiling their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

We saw records indicated people admitted to the home with pressure damage. Their skin improved and . Action was taken to effectively reduce the incidence of falls for one person. People who were frail received kind, appropriate and respectful care that met their needs and maintained their health as far as possible.

People's needs were taken into account with the layout of the home enabling people to move around freely and safely. The premises had been adapted to meet the needs of people with physical impairments within the limits of the older part of the house. People confirmed they were able to see their visitors in private and visiting times were flexible. We discussed with the manager the design of some of the en-suite facilities and the importance of people being able to make choices about the suitability of their rooms.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People we spoke with were satisfied with the care they received at the home. One person told us “I am very happy here. If I didn’t like it I would have gone.” Another person said “I get all the help I need and certainly have no complaints.”

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.We saw one of the people who were cared for in bed. We noted they appeared warm and comfortable. They had a call bell within reach to enable them to summon help if they required it. We saw the manager approach the person to adjust their pillows. They were clearly very pleased to see the manager and very relaxed and happy with the attention they received.

Is the service responsive?

The service recognised people wanted to live their lives in different ways and supported them to do so. Some people enjoyed being part of the home community while others preferred the peace and quiet of their own rooms.

People knew how to make a complaint if they were unhappy. Relatives told us the manager kept them informed. One relative told us they were “300%” satisfied with the care their family member received. We saw an incident when a relative had not been satisfied was dealt with formally. People said that they were able to raise issues "at any time" with the manager.

Is the service well-led?

The service had a manager who was registered with the Commission. The service was well led because the manager was responsive and accessible to people in the home. They knew the people who lived in the home very well and were committed to their well-being and care. The service worked with other agencies and services to make sure people received their care in a joined up way. The service identified shortfalls in the service and addressed them promptly although some aspects of record keeping needed to be improved. As a result the quality of the service was continuingly improving.

You can see our judgements on the front page of this report.

We spoke with three of the residents and a family member. All spoke very positively about the home. One person said "This is a lovely place". Another told us "They look after you very well".

We observed that people's privacy and dignity were respected and that they were included in making decisions about their care. They were encouraged to be as independent as possible and their families were encouraged to spend time with them.

There was a team of committed staff who provided a sensitive and caring service. They demonstrated a good understanding of the needs and wishes of residents and their families and created a friendly and welcoming environment. However, the process for recruiting and selecting staff was haphazard and record keeping was ineffective.

There was a system for monitoring the quality of clinical care but there was no evidence that policies and support services had been monitored. There were few risk assessments or action plans to address or reduce risk.

We inspected Vicarage House Nursing Home to follow up a compliance action made at their last inspection which took place on 30 July 2012. The compliance action was made against Outcome 4 Care and Welfare. We noted that care plans failed to provide sufficient information on how to achieve identified goals.

During this inspection we found that the registered manager had worked with outside agencies to review their care plans. They had introduced a care plan system that was person centred and included associated risks and control measures.

During this inspection we also reviewed the management of medication. We had received information of concern that medication was not being managed appropriately.

We found that the receipt, storage and administration of medication was managed safely within the Royal Pharmaceutical Society guidelines.

We did not speak to people who lived in the home during this visit. However at the last inspection on 30 July 2012 people told us they were happy with the care and support they received. One person told us they would have preferred to be in their own home but, "they are very good you're kept clean and tidy". They confirmed to us that they preferred to remain in their own room but knew activities were available. Another person told us, "I like it here; I wouldn't want to go anywhere else". They also confirmed they enjoyed the food and said, "Staff are very good and if I had any concerns I would talk to matron".

This visit was carried out to follow up concerns raised about the way people with dementia were treated with regards to respect and dignity; and how people would be safeguarded from abuse.

As part of this visit we followed up an improvement action made at the last inspection which took place on 01 February 2011. The improvement action was made against Outcome 4 Care and Welfare. It had been noted that care plans failed to provide sufficient information on how to achieve identified goals.

We also looked at outcomes 14 and 16 which related to staff support and how the provider assessed the quality of service provided.

We discussed the concerns raised with the manager. She told us she had also had a meeting that morning with a representative from Somerset Adult Services. The manager confirmed that she would take appropriate action to ensure people were cared for in a safe manner and would investigate the concerns raised using the home’s complaints and disciplinary procedures.

People spoken with told us they were happy with the care and support they received. One person told us they would have preferred to be in their own home but, “they are very good you’re kept clean and tidy”. They confirmed to us that they preferred to remain in their own room but knew that activities were available. Another person told us, “I like it here; I wouldn’t want to go anywhere else”. They also confirmed they enjoyed the food and said, “Staff are very good and if I had any concerns I would talk to matron”.

We talked to one person about their choice of lifestyle in the home, they told us, “I can make a choice about how I spend my day, it’s not too noisy and I can come and go as I like”.

We asked the manager to show us around the home. The manager told us that there was a programme of refurbishment planned to upgrade facilities and to ensure that some double rooms were divided to offer single accommodation. We noted that the double rooms had privacy screening via the use or curtains. However one double room only had a wooden lattice screen, the manager told us that staff would place a sheet over the screen to promote privacy.

During our visit we observed staff interactions with people. Every interaction was happy, friendly and respectful. People could sit in communal areas or chose to stay in their room.

We observed staff using manual handling equipment appropriately and respectfully, however we then saw staff using the hoist to transport a resident from the lounge to another area. This was not safe practice and we reported this to the manager. She told us that transporting people on the hoist was not the usual practice in the home and she would take appropriate measures to ensure the staff concerned would receive further training in the correct use of equipment.

At lunch time we observed staff offered people a choice and provided alternatives if they were not happy with the options available. One person told us, “I always enjoy lunch it is always worth waiting for”.

We received information about the home that suggested people’s needs were not being met appropriately. The information also suggested that there was not enough staff on duty to meet people’s needs and call bells were not being responded to quickly.

Many of the people currently living in the home were unable to communicate verbally. Those who were able told us that they were happy living at the home and said they received good care. People who were able told us that carers are often busy but added that they felt they worked hard to help them. Some people said they liked the fact that carers take their time getting them up in the mornings. They said carers always make sure their care is delivered at their pace and they didn’t feel rushed. We spoke with someone who received day care facilities. We were told that the carers and manager were “wonderful” and the food was “very good”.

During a visit we observed carers delivering care in a respectful and patient manner. The morning routine appeared relaxed with people getting up at a pace that seemed to suit them. Most people received their breakfast in bed with the support of staff.

People who were frailer were still in bed late in the morning. These people had already had breakfast and drinks and some had gone back to sleep. Staff said they would rather get people up earlier but there was not enough staff to do this. On the day of the visit there were 29 people living in the home. The majority of people required assistance and support with care. On duty, there were six carers, one trained staff, the manager, a cook, a kitchen staff, cleaner and a laundry staff.

When we asked staff if people would rather get up earlier, staff gave a mixed response. Some said that many people liked to stay in bed longer. Some staff said they often changed the routine to suit individual choices. Some staff said there was no choice for people it was down to staffing levels. We spoke with someone who was late getting up, they told us they didn’t mind and said sometimes they got up early and sometimes later. They said if they asked to get up early staff would always help them to do so. Two other people told us they preferred to get up late and liked the fact this was respected. The manager said if people want to get up early they can but most people appreciate the relaxed routine.

Some people told us that they often used their call bell and staff members always respond quickly. During a visit to the home, we heard the call bell being used on a number of occasions for different people. Staff responded in a timely manner.

We observed staff using manual handling equipment appropriately and respectfully.

We read a sample of care records. On the whole, the records were organised well. People’s needs and risks were identified with some actions recorded on how to meet them. Some care plans had a record of people’s preferences for getting up in the mornings and going to bed at night. There was monthly summary on people’s feedback to their care. This was either gathered from what information carers received from people living in the home, or from the carer’s observations and knowledge of the person.

The care records for each person had a sheet of paper with a list of goals and aims. For example, “motivate”, “be aware of time and place”, reduce depression”, “reduce anxiety at night”. Some of the goals and aims recorded had been achieved. There was no description to explain what each goal meant and how to achieve it. The manager told us that staff members have a good knowledge of people’s needs and how to achieve them. Staff spoken with confirmed their knowledge of people’s needs and risks. Many of the staff had been working at the home for a number of years. Newer staff members said they worked closely with experienced staff. Staff told us they receive a full handover each morning where they cover everyone’s needs and any changes to risk, care or support.

This inspection was unannounced and took place on 30 September and 05 October 2015.

There was not registered manager in post, the new manager had been in post since May 2015 and had sent his application to the Care Quality Commission to become the 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.

The last inspection of the home was carried out in April 2014. During that inspection we found records of people's care were not always sufficiently accurate and appropriate to ensure people were protected from the risks of unsafe or inappropriate care and treatment. Improvements were also required to the records of staff recruitment and other records relating to the running of the home. We did not receive an action plan from the provider detailing how and when they would make the improvements. At this inspection we found changes had been made to the way records were kept and maintained. Care plans were up to date and accurately reflected the changing care needs of people in the home. Staff records were well maintained and contained all the information required by the regulations. Minutes of meetings showed issues had been discussed and action taken.

Before the inspection concerns had be raised about the lack of clinical and management experience of the new manager. At this inspection we found the manager had 20 years’ experience within management and a management qualification. They had also worked alongside the previous registered manager before they left. The manager was also supported by a qualified nurse who took the clinical lead role in the home. This meant people benefited from a team with both managerial and clinical skills.

People, staff and relatives told us there had been a lot of changes in the home since the new manager had taken up the post. They all said they felt the changes had all been for the better. One person told us they now enjoyed regular activities and entertainment and had enjoyed the recent quiz. A relative told us they had had their reservations about the changes but they were very happy and felt the home was more cheerful and relaxed.

The manager’s vision was for people to be involved in their care and the running of the home. They had implemented changes to care plans and had carried out care reviews with people and their relatives when necessary. This meant people were beginning to have a say in the way their care was provided. The manager had also looked at the way they could start resident and relative meetings with people making decisions about the way the home would be run. A customer satisfaction survey had been introduced and the manager confirmed once they had received all the responses they would develope an action plan to discuss with people relatives and staff. However this was all recently implemented and it was too soon to judge if the changes could be maintained consistently.

Staff confirmed they all had a very good knowledge of people’s specific needs and would be attending training updates once it was rolled out. The manager confirmed all staff needed their training up dated. A training programme had been arranged with a local college and dates had been booked for all staff to attend. Arrangements had also been made with a qualified nurse to carry out regular visits to the home to assess staff competence and provide training on specific areas such as diabetes.

The provider had a robust recruitment procedure which minimised the risks of abuse to people. Staff said they knew how to report any concerns and people who lived at the home said they would be comfortable to discuss any worries or concerns with the manager.

Everybody told us they felt safe living in the home, one person said, “Safe as houses.” Whilst another person said they felt very safe when being cared for by the staff. Everybody was relaxed with staff and there was a friendly atmosphere on both days we were in the home. Relatives said they were always made welcome and one relative said, “Home from home I visit that often.”

People were supported by sufficient staff to meet their needs. People spoken with said they felt there were enough staff working in the home. One person said, “I think they have enough staff they have time to sit and chat with you so not rushed off their feet.”

Records showed there were adequate staffing levels on each shift. The manager confirmed staffing levels could be flexible to meet the care needs of people and to support other staff with activities. We observed staff took the time to chat and socialise with people and call bells were answered promptly.

People saw healthcare professionals such as the GP, district nurse, chiropodist and dentist. Staff supported people to attend appointments with specialist healthcare professionals in hospitals and clinics. Staff made sure when there were changes to people’s physical wellbeing, such as changes in weight or mobility, effective measures were put in place to address any issues.

Everybody spoken with told us they enjoyed the food, they all said the food was good. People were offered choices and the food was nutritious and well presented. People who needed assistance with eating were supported in a dignified and unhurried manner. People were able to choose were they ate and some people preferred to remain in their own room.