Archived: Vicarage Court Nursing Home

Updated 3 October 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection visit took place on the 23 and 30 August 2017 and was an unannounced focused inspection. We carried it out to see if the provider had taken the actions we told them to take following our comprehensive inspection on the 1 August 2017 where they were rated as inadequate. The inspection visits were carried out by one inspector, an inspection manager and a specialist nurse advisor.

On this occasion we did not ask the provider to send us a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. However we offered the provider the opportunity to share information they felt relevant with us.

We spent time observing care and support in the communal area. We observed how staff interacted with people who used the service. We spoke with four people who used the service and two relatives. We also spoke with three members of care staff, a senior member of care staff and a kitchen assistant. In addition we spoke with two registered nurses, the manager and the provider. We did this to gain people's views about the care and to check that standards of care.

We looked at the care records for eight people. We checked to see if the care they received matched the information in their records. We also looked at records relating to the management of the service, including quality checks and staff files.

Updated 3 October 2017

We carried out an unannounced comprehensive inspection of this service on 1 August 2017. Breaches of legal requirements were found. We undertook this focused inspection on 23 and 30 August 2017 to check that legal requirements were being met. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Vicarage Court Nursing Home on our website at www.cqc.org.uk”

The service was registered to provide nursing care for up to 39 people. At the time of our focussed inspection 31 people were using the service.

The service did not 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.

The focus inspection was carried out to see if the provider had made improvements required to keep people safe. We found no improvements had been made. The overall rating for this service is 'Inadequate' and the service is 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, it 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 if they do not improve. This service has been kept under review and, if needed, urgent enforcement action could be taken.

The inspection was also prompted in part by a notification of an incident following which a service user died. This incident may be subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk. This inspection examined those risks.

Since this inspection a decision has been made that people have moved and will continue to move out of this service.

People using the service were not supported safely. We saw people had not received safe care and treatment as risks to people were not managed in a safe way. People were exposed to risk as they did not receive the correct wound care they required. People did not always receive their medicines as prescribed; the systems that were in place to monitor medicines within the home were not effective in identifying concerns and placed people at risk. Equipment within the home was not maintained or tested to ensure it was in correct working order which meant people could not receive the support they required. People and relatives raised concerns with staffing levels within the home.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.