The Old Vicarage

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people were at risk of avoidable harm. The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always manage or monitor people’s safety effectively. Records showed people had previously fallen in communal areas when no staff had been present. An overview of falls identified a way to reduce these risks was to increase the effectiveness of staff supervising the communal lounge area. On our inspection we observed people in the communal lounge area with no staff present to monitor and help manage their falls risks. However, records showed referrals were made to help people obtain the support they needed from other healthcare professionals when needed.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not work well with people to understand and manage risks. Not all staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks relating to people’s care had not always been mitigated. As reported in our ‘Safe environments’ section, people told us and we observed examples of when care had not been provided in line with recognised safely guidelines. However, people’s communication needs were known and records showed people were monitored following incidents such as falls.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. Equipment to transfer people had not always been used safely. One person told us staff had transferred them in a wheelchair with only one footplate. This wheelchair had not been taken out of action and was still available for staff to use. We observed staff attempt to transfer a person in a way that had the potential to cause harm to them. At other times staff had not created enough space for a person using a walking frame to sit on a dining chair with ease. The premises were not always safe. An area of ceiling outside people’s bedrooms had a large hole with the potential for debris to fall through. Areas of flooring were of a different colour and level and some flooring had torn. This increased the risk of falls to people. Wardrobes in people’s bedrooms had not always been securely attached to walls. This presented a risk from furniture toppling over and causing injury to people.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff had the right skills and competence. They did not always work together well to provide safe care that met people’s individual needs. Not all staff had the skills and competence to provide care to people in line with recognised good practice on how to safely help people transfer. Staff were not always deployed effectively so as to provide supervision of communal areas to help manage and mitigate falls risks to people. The manager had identified 2 domestic staff were required to complete the required levels of cleaning. However, there had often been occasions when just 1 cleaner was on the staffing rota, and some occasions when there was no cleaner identified on the staff rota. Cleaning schedules showed less cleaning tasks were completed when there was only 1 cleaner working. People told us they had to sometimes wait for staff to help them. One person said, “I went to the toilet and

rang the buzzer, and no-one came.” Staff told us there were certain times when they felt they needed more staff. For example, when they needed to supervise communal areas as well as responding to people’s personal care needs.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading. The internal foam was exposed on a chair and wheelchair arm which meant it could not be effectively cleaned. Other furniture was chipped and fittings such as a toilet seat and tile splashback on a handwash sink were chipped or peeling that meant they could not be effectively cleaned. Some areas of the home had not been adequately cleaned and looked visibly dirty. A sluice room was unable to be kept locked as the bolt did not work. This presented safety risks to people from the risk of infection. Some areas of flooring had torn and therefore could not be effectively cleaned. Foot operated bins in toilets did not work and so had to be opened by hand. This increased the risk of infection to people.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.