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Ilsham Valley Nursing Home Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 13 March 2019

We carried out this unannounced comprehensive inspection on 15 October 2018.

Ilsham Valley Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. The service provides care and accommodation for up to 23 people. On the day of the inspection 20 people were living at the service.

The service had 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.

At our last inspection in July 2017 the overall rating for the service was Requires Improvement because people were not always protected from risks associated with their care, and fire prevention and portable appliance testing (PAT) were not safe. We also found, the recruitment of staff was not always carried out safely, and people were not always protected from infection control practices. In addition, people’s records relating to their care were not always accurate and the provider’s systems to monitor the quality of care people received were not robust, in identifying when improvements were needed. Following our inspection, the provider submitted an action plan to the Commission, detailing how improvements were going to be made. However, whilst some reactive improvements had been made as a consequence of our previous inspection findings, we found there was a continued breach of regulation and 17 of the Health and Social Care Act 2008 (Regulated Activities 2014), and additional areas were now requiring action. Therefore, the rating of Requires Improvement remained.

People were not always protected from risks associated with their care. People had risk assessments in place to help guide staff to deliver safe care in line with people’s individual needs, such as moving and handling, skincare, personal care and behaviour. However, people’s risks assessments did not always provide sufficient detail about how to mitigate associated risks. This meant people may not receive consistent and safe support.

People’s medicines were not always managed safely, because the medicines fridge was found to be unlocked, people's medicine records were not always accurately and topical creams were not always dated upon opening. People were supported by sufficient numbers of staff and a consistent staff team, with one person telling us “I see the same carers and nurses, the faces don’t change much”.

People and families told us they felt “Safe”, with one person commenting “I feel safe and comfortable here”.

People were protected from abuse. Staff told us they would not hesitate to raise any concerns with the registered manager if they felt someone was being abuse, mistreated or neglected.

People, at our last inspection in July 2017, were not protected by the provider’s own recruitment procedures, but at this inspection we found action had been taken to ensure people were fully protected.

Overall, people were now protected by infection control practices. There were paper towels, soap and pedal bins in bathrooms. People now lived in a safe and secure environment. Action had been taken to ensure the premises met fire regulations and PAT had been carried out.

Overall, lessons were learnt when things went wrong, and the learning used to help improve the service. For example, the provider had acted to improve the service following our last inspection.

People’s needs were assessed p

Inspection areas

Safe

Requires improvement

Updated 13 March 2019

Aspects of the service were not safe.

People continued to be at risk of harm or illness because documentation regarding the management of risk was not always accurate.

People’s medicines were not always managed safely.

People were supported by sufficient numbers of staff. However, potential risks associated with the development of care staff into clinical roles, had not been effectively assessed. Consideration had not been given to the impact on nursing accountability and responsibility.

Overall, people were now protected by infection control practices.

People were protected from abuse. There were now safe recruitment practices in place.

People now lived in a safe and secure environment.

Overall, lessons were learnt when things went wrong, and the learning used to help improve the service.

Effective

Good

Updated 13 March 2019

The service was effective.

People’s needs were assessed prior to them moving into the service.

People received care and support from staff who had received training to meet their needs.

People received enough to eat and drink, and told us the food was nice.

The service worked well with external organisations to the benefit of people.

People were encouraged to live healthy lives, and their overall wellbeing was promoted.

The design and decoration of the service met people’s needs.

People’s communication needs were known by staff.

People’s human rights were protected.

Caring

Good

Updated 13 March 2019

The service was caring.

People received care from kind and compassionate staff.

People were involved in their care, as far as possible.

People’s privacy, dignity and independence was promoted.

People’s individual equality and diversity needs were met and respected.

Responsive

Good

Updated 13 March 2019

The service was responsive.

People received personalised care. However, we have recommended that people’s clinical care plans, take account of relevant best practice.

People told us they felt confident to raise any concerns.

People were supported at the end of their life with compassion.

Well-led

Requires improvement

Updated 13 March 2019

The service was not always well-led.

People continued to live in a service that the provider did not effectively and safely monitor. The provider’s systems and process were not robust and had failed to identify the areas which had been found to require improvement, as part of this inspection.

The provider had failed to ensure there was clinical oversight and support to the management team to ensure safe and up-to-date nursing practice was followed.

There was a positive, empowering and inclusive culture which had been created by the registered manager.

Staff were motivated by the people they supported and wanted to do a good job.

People's feedback about the service was sought and their views were valued and acted upon.

The service worked positively with external agencies in order to help continuously learn and improve.