Archived: Ivy House Nursing Home

Updated 11 February 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked 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 took place on 5 November 2014 and was unannounced.

The inspection team consisted of one inspector, a bank inspector an inspector manager, a specialist advisor in quality assurance and governance and an expert by experience in nursing care. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection we reviewed the information we held about the home. This included information from the provider and speaking with the local authority contracts and safeguarding teams. Before the inspection, the provider completed 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.

On the day of our inspection we spoke with eight people who lived at Ivy House Nursing Home, one relative who was visiting the home, seven members of staff, the registered manager, service manager, a general practitioner, a community psychiatric nurse and psychiatrist. Prior to the inspection we spoke with another psychiatrist.

We spent time observing care in the lounge and dining room and used the Short Observational Framework for Inspections (SOFI), which is a way of observing care to help us understand the experience of people using the service who could not express their views to us. We looked around some areas of the building including bedrooms, bathrooms and communal areas. We also spent time looking at records, which included five people’s care records, four staff recruitment records and records relating to the management of the service.

Updated 11 February 2015

We inspected Ivy House Nursing Home on 5 November 2014 and the visit was unannounced.

Our last inspection took place on 23 April 2014. At that time, we found breaches of legal requirements relating to privacy and dignity, care and welfare, safeguarding, staffing and the statement of purpose. We asked the provider to make improvements and they sent us an action plan telling us they would be fully compliant in all areas by 1 October 2014. On this visit we found insufficient improvements had been made.

Ivy House Nursing Home is a 40-bed service and is registered to provide accommodation and personal care for older people, younger adults, and people living with dementia or mental health conditions. Nursing care is provided. At the time of our visit there were 23 people using the service. The number of people using the service had reduced as following our last inspection placements were stopped by the organisations who commission and pay for the service.

The accommodation for people is arranged over two floors. There are single and double bedrooms and some rooms have en-suite toilet facilities. There are communal bathrooms and toilets throughout the home. The communal rooms are on the ground floor and there is a separate dining room.

The home has a registered manager who is also one of the owners. 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 and associated Regulations about how the service is run.

We found the service was not well led. The registered manager did not have a good understanding of governance and the quality systems that were in place were not effective. There were no ‘lessons learnt’ from accidents, incidents and complaints to demonstrate what action had been taken to try and prevent them from reoccurring.

We found people’s safety was being compromised. Procedures to keep people safe were not being followed. We were concerned about fire procedures in the home and following our visit we asked the fire officer to visit.

The home smelt strongly of stale urine and faeces and some areas of the home were poorly maintained.

There were not always enough staff on duty to make sure people received the care and support they needed. Not all of the staff had received the training they needed and staff were not always following people’s care plans.

We found the service was meeting the legal requirements relating to Deprivation of Liberty Safeguards (DoLS).

People were receiving the healthcare they needed from a range of health care professionals, who told us they felt the staff were providing good care and support. This information contradicted our findings on the day of the visit.

We found there were people who had lost weight and staff were not monitoring their weights to see if the food supplements they were being given were effective.

We saw staff were patient and respectful in their direct dealings with people, however, not everyone was being supported to live their life in a dignified way.

We found on-going breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.