Archived: Ivyhouse Care Home

At our last inspection we were concerned that people were not being kept safe. There were not enough staff on duty and staff were not being delegated to meet people’s needs. People could not be certain their medicines would be managed and administered safely. The nursing care provided had not consistently been well planned or delivered to ensure people’s health care needs were met. At this inspection we found significant improvements had taken place however people were still not receiving a service that was consistently providing safe care.

Ivyhouse is registered to provide nursing care and accommodation for up to 76 older people who may also be living with dementia. At the time of our inspection there were 27 people living at Ivyhouse on Daffodil and Cornflower Units. During our inspection people were being assessed for new care homes and some people were being supported to move out.

There was no registered manager in post, but the registered provider had ensured someone was in day to day control of the home. They were present throughout our inspection and were supported by a member of the registered provider’s management team. 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.

We completed this unannounced inspection on 22 September 2016. We planned this inspection to provide assurance that plans were in place to provide an adequate level of care and support to people until the home closes. We only looked at the key question of safe. This report only covers our findings in relation to the key question of safe. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ivyhouse on our website at www.cqc.org.uk.

While the provider had taken some action to improve the management of medicines this was not consistent across the home. Medicated creams and tablets administered directly from boxes were not well managed. People could not be confident they would always receive these as prescribed.

Risks people were exposed to because of their medical conditions had not always been identified, assessed and well planned for. People could not be confident they would always receive care that protected them from harm.

Although there were less people using the service the provider had not reduced the number of staff working at the service. This had resulted in staff having more time to spend with people and time to focus on their needs. People told us the staff were caring and responsive to their needs. People told us they felt safe and medicines that were administered from a blister pack were well managed.

People told us they enjoyed the food and we observed people being provided with the support they needed to eat and drink. People appeared well presented and staff took action when necessary to maintain their dignity. People were supported when necessary to access a range of health care professionals.

A range of checks and audits had been developed to drive forward improvement at this service and to ensure people safely received the care and support they required until they left the service.

As Ivyhouse is a service in special measures it will be kept under review while it is open. Where necessary, another inspection will be conducted whilst the home remains open. The findings of future inspections could lead to us taking urgent action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

We last visited Ivy House Care Home on 11 and 12 June 2014 to follow up on compliance actions we had made in December 2013. At our visit in June 2014 we found that significant improvements had been made but that the service was still non-compliant with four of the essential standards we inspected. The provider sent us an action plan detailing how they would improve the service. Since then they have updated us regularly about how this has been working. We visited the home again on 11 September 2014 to see if compliance had been achieved in two outcome areas. We inspected the home to see if people were getting safe and appropriate care that met their needs and supported their rights and to see if the service had quality checking systems to manage risks and assure the health, welfare and safety of people receiving care.

The home is divided into four separate units, Daffodil, Tulip, Cornflower and Rose. Each unit has a communal lounge, dining room, bathroom and individual ensuite bedrooms. Tulip is an enablement unit, up to 16 people can stay here for up to six weeks to recover after a period of time in hospital. There are also four permanent residents who have nursing needs. Daffodil is home for 18 people who have nursing needs and are living with dementia. Cornflower unit provides care for up to19 people who have a nursing care need and one person who needs enablement. Rose is a unit for up to 18 people who are living with dementia and have residential care needs.

Below is a summary of what we found. The inspection findings are based on our observations during the inspection, discussions with 12 people using the service, eight people's relatives, six of the staff supporting people living at the home, talking to four health and social care professionals and looking at some of the records the home is required to maintain.

Is the service safe?

We found that people were receiving the care they needed, and were being supported by staff they knew and liked. Relatives told us they felt confident their relative was safe, one person told us, "I can go out of here with my mind at rest knowing she is being looked after."

We found the systems in place to check on the safety and quality of the service had improved. This meant that risks to people's safety and welfare were more likely to be identified quickly and acted upon, which would protect people from avoidable harm.

Is the service effective?

People's health and care needs had been assessed and written care plans had been written from these. People and their relatives told us they were happy with the care and shared examples where people's health had improved since they had lived at the home. We found pressure area care was being effective as people who had been assessed as at high risk of developing sore skin had maintained their skin in good condition.

Is the service caring?

We observed and heard staff supporting people with kindness and compassion. We heard people enjoying a laugh and a joke together and one person told us, "Everyday they try and have a little bit of fun with us." Staff we spoke with demonstrated warmth and interest in the people they were caring for. Staff were able to describe people's preferences and had knowledge about their family and life history. This enabled them to care for each person in the way they preferred.

Is the service responsive?

We found evidence that the manager acted quickly when concerns were brought to their attention. Staff we spoke with were aware of possible signs of ill health and described how they would call for a nurse, who may in turn request further medical support. We saw this process in action during our inspection, which ensured people got a prompt medical assessment and treatment if needed.

Is the service well led?

People told us they had confidence in the ability of the management team. Some relatives and members of staff shared examples with us of action taken by the manager in response to their concerns or suggestions. One health professional we met told us, "I couldn't ask for a better person to work with. She goes out of her way for us."

People had opportunities to make suggestions and comments about the running of home in meetings, in person and by using surveys issued by the home.

The home had developed an action plan to ensure they were meeting the requirements of the law and that they were providing a service that people would chose to use. We found evidence that the homes' management team was using the action plan effectively to drive up standards within the home.

In December 2013 we inspected the home and at that time found that the home was non-compliant with seven of the essential regulations. We issued compliance actions to ensure these areas of non-compliance were addressed and to ensure the service improved for people living at Ivyhouse. We conducted this inspection to follow up on the issues of concern and see what progress had been made. Generally we found that many improvements had been made although the home had not yet achieved full compliance in all of the regulations we assessed.

The home is divided into four separate units, Daffodil, Tulip, Cornflower and Rose. Each unit has a communal lounge, dining room, bathroom and individual ensuite bedrooms. Tulip is an enablement unit, up to 16 people can stay here for up to six weeks to recover after a period of time in hospital. There are also four permanent residents who have nursing needs. Daffodil is home for 18 people who have nursing needs and are living with dementia. Cornflower unit provides care for up to19 people who have a nursing care need and one person who need enablement. Rose is a unit for up to 18 people who are living with dementia and have residential care needs.

Below is a summary of what we found. The inspection findings are based on our observations during the inspection, discussions with 16 people using the service, nine people's relatives, seven of the staff supporting people living at the home talking with 11 health and social care professionals and looking through some of the records.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

Staff we spoke with understood their role in safeguarding the people they supported and they had access to the homes own safeguarding procedure. Staff demonstrated no tolerance for abusive practice and told us they felt confident to raise any concerns with the manager.

People living at Ivyhouse and their relatives told us they felt safe. Their comments included, "I feel safe" and "The home has not been neglectful in anyway."

We found that people were at risk from some parts of the premises which were not as hygienic or clean as they should have been.

Records showed that all the equipment and services such as the gas and fire safety system had been maintained and serviced regularly.

We looked at the recruitment of new staff. Staff recruitment records showed that all required recruitment checks were being undertaken. This was a way of ensuring people were supported by staff with the appropriate skills.

Is the service effective?

People's health and care needs had been assessed and risks related to people's health had been identified and planned for. However some of the care plans had not been reviewed regularly and lacked details of how people's needs had changed. The care plans were therefore not all able to support staff to meet people's needs in a consistent way.

Some people we met were using the intermediate care unit at Ivyhouse. People told us the support and care they received there had enabled them to regain the skills and confidence they needed to return home. We looked to see if the care given to people at risk of getting sore skin or of losing weight was being effective. We found care in these areas was being effective as people were not developing sore skin, and most people at nutritional risk were gaining weight.

The service undertook a number of checks and audits to establish how the home was running. These had been mainly effective at identifying the areas that needed to change or improve but had not been so effective at ensuring the changes were made or that the changes made had been maintained.

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 commented, "I am very, very happy here" and "The staff can't do enough for you". Relatives we spoke with were pleased with the support given to their relative. One family told us," Staff here are all really friendly and helpful. She (our relative) is so settled and happy, it is far more than we could have hoped for."

Is the service responsive?

During this inspection we identified a number of issues about which the provider took immediate action to rectify or improve the situation and to ensure people's care and support needs were being met.

We observed staff on duty were quick to identify changes in peoples' well-being. We observed care staff bring concerns to the nurses attention, and we observed nurses seeking advice from the person's doctor or the relevant professional.

Relatives we spoke with shared examples of how requests had been quickly actioned without any fuss. One family explained that their relative had moved rooms twice at his request, another family explained how the staff had supported re-arranging some bedroom furniture to make the room work better for their family member, and another how their relatives medicines had been changed from tablets to liquid solutions as their condition changed. They told us, "This was done almost immediately with no fuss or moaning."

Is the service well-led?

The leadership of the home had recently changed. A new manager and some new senior nurses had been recruited. People we spoke with praised the changes and their comments included," The management has been helpful and approachable", " The unit manager I work with is amazing, I could only sing her praises" and" Before, people largely did what they wanted, people are now much better managed."

People we spoke with told us that they had been asked if they were happy with their care and had been given opportunities to make suggestions about how things could improve. One person we spoke with said, "You can ask them for anything". When asked if there was anything at all they would wish to change some people said "No, nothing".

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

People's needs were assessed prior to admission to the home but people did not always receive the care, treatment and social care they required. We saw that care planning was at times incomplete, which meant that staff lacked guidance in giving people effective care. People who required regular baths or showers did not receive them in a timely manner. One person told us: 'I am a bit overdue a shower.' .

Appropriate precautions had been taken to ensure that staff recruited were of good character reducing the risk that people would be cared for by unsuitable staff. One visitor told us: 'I have never felt concerned for my relative in that way.' But people were not fully protected from the risk of abuse occurring as the staff had not been trained to ensure that they followed best practice guidelines or its own policies, particularly when people were unable to make decisions which were in their best interests.

People were cared for in an environment that was not always clean. We found one unit in need of cleaning due to poor odours and food residue. Items for washing and toiletries in one communal bathroom could not be identified as belonging to any specific person. This put people at risk of infections from living in an unclean environment and at risk of sharing personal washing items.

The service had a hoist available for staff to use but people were at risk from receiving an injury because we saw that some lifts were performed without the use of a lifting aid. We saw a lack of transfer equipment which could reduce a person's independence and mobility ability.

The provider operated with a statement of purpose which outlined the service on offer to people. This was up to date and shared with the commission.

People were cared for by an insufficient number of staff. This meant that people had to wait for the care and treatment they required and were at times at risk of not receiving it such as activities. The staff turnover was very high. The service specialised in dementia care and people were at risk of becoming disorientated by having an inconsistent staff team.

Staff were not always supported. Staff appraisals and supervision meeting were infrequent for long standing staff and staff told us they did not feel supported in their role. However, staff who were receiving induction training did advise that they felt supported by both colleagues and line managers.

The systems in place for monitoring and assessing the service were ineffective and failed to identify and address issues that impacted on positive outcomes for people using the service.

Many of the people who lived in this home had complex needs and were not able to speak with us in detail about their experiences. In order to find out about people's experience of this home we spent time observing how staff cared for people.

We used the Short Observational Framework for Inspection (SOFI) on Cornflower unit which provides nursing care. We also observed care provided to people on the other two nursing care units, Daffodil and Tulip, and visited the residential unit Rose. We spoke with staff and visitors on all units and visited the kitchen and spoke to the chef.

One person said, 'The girls [care staff] work very well together'.

Another person said, 'Since the arrival of the new manager, the home has seemed cleaner' and added that, 'The staff appear to have more direction and to be more motivated'.

A member of staff said "I enjoy my job greatly", another said that, "More structured management, staff incentives and more support was needed"

At the time of our inspection 48 people were using the service and most of the people had been living in the home for some time. There had been no new admissions over the past few months.

We found at this inspection that care and welfare needs of people were being met. People were involved in planning how their care needs would be met. Activities which had a positive impact on people's daily lives were available.

Nutritional arrangements were meeting people's needs. More choices of meals and drinks were offered to meet their needs and preferences.

Safety of people within the service had improved as the provider has taken all reasonable steps to ensure people were protected from risks of abuse and any risks arising from the use of faulty equipment. Medication was managed safely so people received what they were prescribed at correct times.

Staff training had improved and staff were supported to undertake relevant training to improve the care they provided which enabled them to meet people's needs.

We found that systems were in place for regular checking and auditing of the care and support provided, with feedback and comments from people used to make further improvements to the service.

Accurate records were maintained, which supported the running of the service.

The service catered for older adults with a range of health issues, including some people with dementia.

We looked at three care files, observed people, spoke with one person, one visitor and five staff, four of whom were involved in direct care.

People could not be confident that their care and welfare needs would be met in full. The systems in place were not robust enough or consistently used to meet the needs of people appropriately.

Food choices and menu arrangements continued to be inadequate.. The systems in place did not ensure that people received the choices of food they wanted. People's individual dietary needs were not universally being met. One person told us, 'I never see any fruit'.

Training of staff for both safeguarding and other mandatory subjects continued to be an issue. The provider had not increased the number of staff attending training. We spoke to staff and one said, 'My skills are OK but I need more'.

The provider had increased the range of quality assurance information available. The provider had not shown that it was acting on this information effectively to improve peoples' experiences.

Records were not always complete and accurate, creating a risk that people did not always receive the care and treatment they needed.

We inspected this service as a result of information we had received form a trusted source. Although we had inspected twice since October 2012, we had not looked at medicines management.

At our inspection we found that the provider did not have robust systems in place. The communication between staff levels led to omissions and overdosing in the delivery and handling of medications. The provider had also failed to ensure that the staff had the skills required and were made aware of the local systems in place in relation to administering and checking of medications.