The Vineries

This service was previously rated good. We carried out this assessment to confirm whether the rating of good remains accurate.

Positive feedback was received from people using the service, their relatives and visiting health care professionals.

We identified concern around staffing. Regular agency staff were used to cover shifts, but agency profiles contained very little information and did not include details about the agency workers previous experience in care or experience working with older people or dementia care. The registered manager assured us that agency staff had an onsite induction and did not work unsupervised. However, on the 1st day of our visit, they were unable to provide clear induction records, and they were unclear if the employment agency carried out supervisions. A recent whistleblower commented on a lack of suitable skills from agency staff. Interview notes were not robust, and interview questions did not relate well to the regulated activity or explore staffs understanding, values and behaviours.

Staff records did not clearly evidence how staff had been adequately supported throughout their induction. or if their competencies had been clearly assessed before working unsupervised.The impact of staff vacancies affected staff morale. The registered manager and deputy manager were covering shifts, including day and night shifts so we were unable to see how they could effectively support and manage staff when working on a spit shift pattern. Following this discussion the registered manager was taken off nights.

Records were disorganised making auditing more difficult as they were not in chronological order. The dependency tool was significantly out of date, (January 2026). The document was very crude and did not take into consideration: Activities, the layout of the building or people’s sensory needs. At least 5 people were described as frail. This was not reflected in the dependency tool.

People had insufficient activity; the activity board was blank. Care staff told us they were busy providing direct care to people and did not have time to provide support with activities. An activities coordinator had been sourced for a few days a week which was not sufficient. People reported not going out and only having external entertainment occasionally. Not everyone at the service had regular visitors making the day monotonous. Lunch time supervision was poor and only 5 people were in the dining room.

Staff told us staffing could be a struggle, but said the care was not impacted and staff were caring. One said, “No its hard on regular staff and agency staff who don’t have the necessary skills.” Another staff said, “Agency won’t know who’s on blood thinners or know who is under a deprivation of liberty safeguard, (DoLs)” Another said, “Some days staff are struggling but go above and beyond.” The impact of staff who were not unfamiliar with people’s needs increased the risks of unsafe care and it was difficult to see how risks were mitigated without a clear induction overview.

Training and supervision for staff was mostly up to date and mostly online. Most staff were experienced and had opportunity to do enhanced areas of study. Direct observations of practice were carried out a minimum of twice a year and people and relatives spoken with felt staff were caring and competent.

Whilst the registered manager responded appropriately to safeguarding concerns and staff knew what actions to take to safeguard people in their care. We found a police incident which had not been reported to us and a hospital admission which resulted in significant safeguarding concerns being raised against the hospital. As the person was still under the care of the home CQC should have been notified.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff and management worked within the principles of the Mental Capacity Act 2005 (MCA). Unnecessary restrictions were not in place. People had communication plans in place to support staff in understanding how people expressed themselves.

Deprivation of Liberty Safeguards (DoLS) authorisations were not in place, although a number of applications had been made but not yet approved. People were not subject to unlawful or excessive restrictions they had choice, control and freedom over their lives.

The home provided an open and inclusive environment and supported those with and without dementia. People’s needs were kept under review, and if a person required additional care a more appropriate environment would be sought. Staff were supported to understand people’s needs, but we identified one person with risk behaviours which had not been clearly risk assessed. This was rectified. Care plans were paper records and contained a lot of detail about how to meet people needs and were person centred. People had keyworkers who oversaw their care but not everyone knew who their key worker was, some people had the key workers name on their door. Staff wrote up notes about people's care and fluid intake later in the day and not contemporaneously. This could open room for recording errors.

Environmental risks were not effectively managed. The ground floor bathroom was out of use and whilst some people had ensuite everyone spoken with had a shower, (so no choice of a bath) and several requested they would like more than one shower a week. Some of the window’s downstairs at the back of the property were facing brick walls. Some other windows/doors, although mostly accessible looked out to poorly maintained patios/overgrown areas. There were old chairs and equipment left outside in view.

In the communal area, the door to outside, had a slope, but was mostly full of moss, and appears to have not been used for some time. This was a fire escape and would become slippery underfoot when wet. The registered manager was advised of this so they could take urgent action. Maintenance support was shared between 3 homes, and several people told us they were waiting for maintenance issues to be resolved.

Whilst hallways were wide and fitted with handrails, the floor sloped in parts and there were no warning signs. Falls were low within the service, but where falls had occurred several people’s, long-term mobility had been affected. Whilst the home-made regular referrals and were well supported by the GP wait times for secondary services were largely outside the homes control.

Infection control was well managed with no odours and mostly wooden floors. People’s rooms were personalised and large objects like wardrobes secured to the wall, but we suggested regular audits to ensure large items were secured as one wardrobe was not secure. Following our visit our feedback has been addressed and evidence provided including further environmental checks and ensuring domestics and care staff were updating and keeping regular records including regular water outlet flushing to prevent legionnaires disease. We also questioned water temperatures as a few hot taps were recording at temperatures over 50 centigrade. Anything over 43 c to 44c increases the risk of scalding.

Safety checks were carried out but at uneven intervals and this did not appear to include the external building. We also noted some fire records contained recording gaps. Personal evacuation plans were up to date, and staff had sufficient knowledge of fire safety.

We recognised the home was facing staffing challenges which was impacting on staffs’ wellbeing. Some long-term sickness was being addressed and recruitment was ongoing. However, staff told us the care was ‘person centred’ ‘people were treated with dignity and care’ and the registered manager and deputy were described as ‘lovely people’, ‘really visible.’ However other staff recognised there was really no time to sit with people and offer them companionship and engagement

Medication was well managed by staff who had a good understanding of medicines and had been assessed as competent in its administration. Any medication error was responded to appropriately, so lessons were learnt. Regular audits helped to identify if medicines were administered effectively.

We identified 1 breach in relation to governance and oversight.

We have asked the provider for an action plan in response to the concerns found at this assessment.