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

Ilsham Valley Nursing Home is a care service with nursing registered to provide accommodation and care for up to 23 people. Most but not all of the people living at the service are older people. The service does not offer care to people with dementia as a primary diagnosis but some people may have some early memory loss associated with other illness or disability.

The service is set over two floors, with a lift to access the first floor. It is set in the Wellswood area of Torquay, close to the sea and local shops and services.

At the last inspection on 15 and 19 May 2015 the service was rated as good in all areas apart from well led, where it was rated as requires improvement. The overall rating was good. At this inspection in July 2017 we found the service had not sustained some of this good practice. We also identified a number of concerns and breaches of legislation. The service has been rated as requires improvement overall.

We found the service did not have strong, effective and robust systems of governance and management. Although we did not identify that people had suffered harm as a result, the failure to have clear accountability for actions within the management structure left people at risk of receiving poor or unsafe care. Some systems for audit had lapsed, and where concerns had been identified by the organisations own processes, such as with fire precautions or infection control there was no clear and well understood plan of action shared within the management team to address them.

Risks to people’s health or well-being were not always robustly assessed and managed and some records regarding their care were inconsistent or did not contain easily available information on people’s current needs. This meant the records could not always be relied upon to provide evidence of changes in people’s needs or health conditions. We have made a recommendation about the updating of care plans. The service had activities available for people to take part in and people’s care plans contained contain information about what interests people had, so staff could tailor these accordingly.

Incidents such as falls or accidents were not currently being analysed and an incident where a person had suffered harm when a bed rail was not put in place had not been reported to the appropriate agencies as it should have been. The service had investigated and taken appropriate action themselves. This did not demonstrate openness or transparency as a service.

People did not always receive safe care in an environment where action was consistently taken to reduce assessed risks. The service had undertaken audits or commissioned risk assessments, some of which had identified concerns about the premises, such as fire precautions, carpets needing replacing or the laundry and sluice areas. While some smaller actions had been taken there was no available or well understood action plan in place for when larger areas would be addressed. This could leave people at risk, and does not demonstrate effective management of the service. The environment was however, homely and comfortable.

We also had concerns there was no person at the service with nursing experience leading the nursing team or assessing the quality of their clinical practice. The provider has told us the registered manager, deputy and nursing staff “work collectively as a Nursing Team to lead the service on a collective basis” and have taken advice from Skills for Care on how this can be demonstrated.

Records were not all well maintained, and appropriate notifications had not always been made to the Care Quality Commission or other services as required by law.

People told us the service met their needs and they were happy with their care. We saw many examples of positive practice in place, with staff supporting people in a gentle and caring fashion. People and staff had developed good relationships and staff told us it was a happy place to work.

People received their medicines sa

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? When we visited the home in March 2014 we found that improvements were needed in some areas. At this visit in May 2014 we looked to see if improvements had been made. We found that a new manager had been appointed and that they had made some significant improvements to the way the service was managed.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

Staff personnel records did not contain all the information required by the Health and Social Care Act 2008. This meant the provider could not demonstrate that the staff employed to work at the home were suitable and had the skills and experience needed to support the people living in the home. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. The manager had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

We found that people’s consent was obtained verbally for care and treatment provided to them by the service. Staff supported people to make choices and decisions about their daily lives. However, where people did not have the capacity to consent to care and treatment, the provider did not have documentary evidence they had acted in accordance with legal requirements. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

People told us that they were happy with the care they received and felt their needs had been met. One person said "I get great care". It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and that they knew them well. We found that staff had not received regular supervision and training that would support them to do their jobs effectively. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff were patient and gave encouragement when supporting people. People told us they were able to do things at their own pace and were not rushed. Our observations confirmed this. We saw and heard positive interactions between staff and people who lived at the home. People told us “I love the friendliness – it’s not stiff and starchy”.

Is the service responsive?

People’s physical and health care needs were well met. However, there was little evidence that people’s social care needs were given as much priority. People told us there had been a recent meeting with the new manager to discuss how the service was going to move forward. A relative told us that the manager had already identified the garden needed to be tidied up. People told us they had never had anything to complain about. However, one relative told us they felt the environment was “looking tired”.

Is the service well-led?

The home had been without a Registered Manager since October 2013. A new manager had been in post for a month prior to our inspection in May 2014. A quality assurance process had only recently been put in place and it was not possible to tell if this would be effective. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

We, the Care Quality Commission (CQC) undertook this inspection as a result of concerns being raised about the management of the home. On the day of our inspection 16 people were living at the home and received care from the service. We spoke with five people, one visitor, the owner, the clinical lead nurse, three care workers, the cook, the domestic and the maintenance person. We looked at three care plans.

One person described the home as a "top notch" Another person told us the staff were “lovely” and that the care was "excellent".

People had clear assessments of their needs and plans and strategies were in place to meet them. We saw that care workers interacted with people in a relaxed and respectful manner. People had access to age appropriate social activities. We saw people had a choice of suitable and nutritious food and drink available in sufficient quantities. People said the food was good. One person said "the food is gorgeous."

People who lived at the home told us that the staff were very good. One person said “they are the best”. There were sufficient numbers of staff on duty. Established staff that had been employed for some time had been appropriately trained and had regularly received supervision and appraisal. However we spoke with three newly appointed staff (appointed within the past three months), they had not received any training or supervision. This means that people could be at risk from receiving poor or inappropriate care.

People told us they were very happy living at the home and felt that they received a high standard of care. People described staff as “kind”. One person said “I have absolutely nothing bad to say about this place. I am looked after very well indeed. The staff are kind, the food is good and I am very happy indeed.”

Staff were knowledgeable about people’s needs and accessed additional health and social care services where required. People felt involved in planning their care and could decide how to spend their day. They also appreciated the activities provided at the home.

People said they felt safe living at the home and knew how to raise any concerns or complaints. People said they could share their views about the care. Staff had received training in the safeguarding of vulnerable adults and knew how to report any concerns.

The environment was safe, clean, tidy and free from obvious hazards. Systems were in place to maintain this safe environment.

All records and documents seen were well maintained, accurate, securely stored and reflected the care people received.

We visited Ilsham Valley to check on progress following a review we carried out in August 2011. During our visit in August 2011 we found that people had not been treated with the respect they needed. Care had not always provided in a safe way, meaning people were placed at unnecessary risk. Routine management checks were also not being carried out to highlight such issues as staff training, staff recruitment and safety of the building.

There had been a change of management at the home since our last visit.

We visited the home with an expert by experience. The Care Quality Commission (CQC) describe an expert by experience as "people who have in-depth experience of using services, and have been trained in their expert role by voluntary organisations."

During the visit we spoke with 8 people who live at the home, 7 members of staff and 2 visitors.

People were happy with the standard of care they received at the home and told us they felt safe living at the home. They said that staff listened and acted on what they said and were respectful when providing care. People were also happy with the way their medicines were managed.

People were also full of praise for the quality and quantity of the food with comments of, “The food is excellent”, “Really good”, and, “You can have seconds”.

The increasing activity programme had also proved popular with people at the home.

People living at the home and their relatives had noticed changes in recent months. One person said, “Things are becoming a lot better now. The new manager is making changes gradually rather than all at once.” A relative said, “We are delighted in the changes that have taken place.”

There were no unpleasant odours and the premises were clean and tidy. One person said, “My room is cleaned every day and sometimes twice a day”. A visitor said, “The standard of cleanliness has improved greatly of late”.

People told us that usually there were sufficient staff on duty but occasionally someone may fail to come on duty because of illness. People had also noticed there had been a change of some staff but said these changes had slowed down in recent weeks, and that they liked the new staff.

A visitor commented, “This place is now run better and more professionally. There have been a lot of little improvements and I understand that staff training is now planned”.

People told us they were able to share ideas or make suggestions and these were listened to. We were also told they would speak to the manager or a named member of staff if they had any concerns.

People we spoke with told us they felt they received ‘a very good service’ and would recommend living at Ilsham Valley Nursing Home.

One person said they liked living at the home but when asked about being respected and treated politely said ‘It depends on who it is. Some staff are better than others.’

People do not always have a clear plan of care which may place them at risk of receiving unsafe care. Other people do not feel involved in their plan of care. One person told us they had blood taken, but added they did not know why this had been done. Another person said ‘I just let them do what they need to do.’

There is not a wide variety of activities at the home. One person said there ‘Is not a lot to do apart from watch TV and read books’. Another person said ‘Many a time I get bored. I’m stuck in my chair and don’t go out because I have wobbly legs.’ Another person said ‘I stay in my room all day, but I don’t get bored.’

The people we spoke with said they felt safe and thought the staff were ‘kind’ and ‘patient.’ We were also told that people felt able to talk to any of the staff if they were unhappy or felt unsafe. One person said ‘The staff are very good, I have no grumbles about that’, whilst another said ‘they are simply lovely.’ One person said they thought the ‘night staff were very helpful.’

People told us they were satisfied with the level of cleanliness at the home. One person said ‘The cleaning is very good’.

Ilsham Valley Nursing Home is situated in a residential area of Torquay, Devon. It is registered to provide accommodation, personal and nursing care for up to 23 people. There is a registered nurse on duty at all times.

This inspection took place on 15 and 19 May 2015. The service was last inspected on 7 May 2014 when we found some improvements were needed. We found several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Regulation 18 was breached in that there was no written record of people’s consent to care and treatment. Regulation 21 was breached in that recruitment practices were not robust. Regulation 23 was breached in that staff were not supported to deliver good care. Regulation 10 was breached in that there was no effective quality assurance system in place. The registered provider wrote to us and told us they would have addressed the required matters by June 2014. At our inspection in May 2015 we found that most improvements had been made, but further improvements were still needed in relation to the quality assurance systems.

Since our inspection in May 2014 the service had identified poor practice by a member of staff. A full investigation had been carried out by the local safeguarding team with the cooperation of the service and this had resulted in action being taken to protect people.

There had been no manager registered at the service since October 2013. A manager had been employed by the service, but had not yet registered. It is a condition of the service’s registration that a manager is registered. 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.

Some aspects of the service were not well led. There was a system in place designed to audit the care provided at the service. However, audits were not regularly completed. This meant there while there were some measures in place to check the quality of care, there was no overall method by which the service could check, maintain or improve the quality of care provided by the service. However, people and their representatives told us they rarely had to raise issues and when they did so, things were quickly put right.

There was an effective system in place to help staff manage medicines safely. However, we found there was no indication of how staff would recognise when a person was beginning to become distressed, or if alternative interventions should be used, before medicine that was prescribed to be taken as required was given.This meant the person was at risk of being given their medicines inconsistently as staff may interpret the person’s distress differently.

At our inspection in May 2014 we found that recruitment procedures were insufficient to ensure people were protected from the risks of unsuitable people being employed by the service. The registered provider told us they would have procedures in place to protect people by June 2014. At our inspection in May 2015 we found that improvements had been made and people were protected by robust recruitment procedures.

People’s risk assessments contained good details on how risks were managed. Moving and transferring and pressure area assessments were in place and had been updated when risks had changed. For example, one person’s moving and handling and pressure area assessments had changed as they were spending more time in bed.

The environment was safe and secure and there were arrangements in place to manage the premises and equipment. Procedures were in place to protect people in the event of an emergency. Staff had been trained in first aid and there were first aid boxes easily accessible around the home.

People’s needs were met in a timely manner as there were sufficient staff on duty. On both days of our inspection there were 17 people living at the home. Only three people routinely spent time in the lounge, with other people spending their time in their rooms. Two visitors told us they felt there could be more staff especially at weekends, but that generally there were enough to meet people’s care needs. People and staff told us they felt there were enough staff on duty. One person said “If I need help they come in pairs” another said “Just press the buzzer and they are there”. During the inspection, call bells were answered quickly and staff spent time talking with people and were on hand to provide support with care needs when required.

People received effective care and support from staff that had the skills and knowledge to meet their needs. Staff had received a variety of training including moving and transferring, dementia care, end of life care and safeguarding adults. There was a system in place to identify when any training was due to be updated. People were protected from the risks of abuse as staff demonstrated a good knowledge of different types of abuse. They told us how they would recognise abuse, and what they would do if they suspected abuse was occurring within the service.

Staff were skilled in meeting people’s needs and regularly offered care to people. Everyone we spoke with told us that people were well cared for. People told us staff knew how they liked things done. One person told us “All the staff know how to help me move”. One visitor told us “Staff are very pleasant and helpful and nothing is too much trouble”. Staff received supervision from more senior staff and an annual appraisal. Regular supervision ensured staff had the opportunity to discuss their work and learning and development in a measured, monitored and supported way.

Staff had a clear understanding of the Mental Capacity Act 2005 (the MCA) and how to make sure people who did not have the mental capacity to make decisions for themselves had their legal rights protected. When people were assessed as not having the capacity to make a decision, a best interest decision was made involving people who know the person well and other professionals, where relevant.

At our inspection in May 2014 there was no written evidence that people had consented to receive care and treatment. At our inspection in May 2015 there was written evidence that people or their representatives had consented to receive care and treatment as described in their care plan. Throughout our inspection people were asked for their consent before staff provided personal care. Staff also offered choices about where the person wanted to sit and what they wanted to eat or drink. People told us that staff often asked them for their views about their care. One person told us they had been involved in developing their care plan.

People were supported to receive a balanced diet with sufficient to eat and drink. People were offered plenty of snacks and drinks through the day. One person told us “meals are very good, plenty of choice”.

People were supported to maintain good health and had access to healthcare services where required. Records showed people had seen their GPs and health and social care professionals as needed. One professional told us staff always contacted them appropriately and followed any instructions they were given. They said they had never had any cause for concern when visiting the service and had nothing negative to say about it.

People and their visitors told us staff were very good and caring and all the interactions we saw between people and staff were positive. Comments from visitors included “I couldn’t do better myself”, “It’s like a great big happy family” and staff are “all very nice, caring and friendly”. One visiting professional told us the staff not only cared for the person living at the home, but for all their family as well.

Visitors told us they could visit the home at any time and were always made welcome. One visitor told us they visited every afternoon and another told us they visited at all times on all days, so staff never knew to expect them. They said things were always just as good whatever time they visited. They told us staff always kept them informed about any changes to their relative’s care.

People’s privacy and dignity was upheld. One person told us “They [staff] always knock on my door even when I’ve called them”. All personal care was provided in private and staff took care to ensure people’s appearance was clean and tidy and that their hair was combed. Staff enabled people to maintain as much independence as possible. One person told us how the service was supporting them to return to a more independent living setting.

People’s care plans were maintained and reviewed regularly. The plans contained comprehensive assessments of the person’s needs and detailed instructions for staff on how to meet personal care needs. Social care needs were not so well assessed on some and there were few details on the person’s past life. This meant staff may not have all the information they need in order to maintain all aspects of well-being. New in depth personalised assessments had been completed for some people and care plans had been developed based on these assessments. Staff were working to complete the new assessments for everyone.

People received individualised personal care and support delivered in the way they wished and as identified in their care plans. Staff told us they always asked people what they wanted and how they wanted their needs met. Where people could not tell staff what they wanted, staff told us they followed the person’s care plans.

People's bedrooms contained personal possessions and were arranged according to their needs. Staff told us how one person’s bed had been moved to make more room for them to move around. Staff and people told us they had time to spend with people on an individual basis. During our inspection we saw that staff spent time chatting to people and helping them complete puzzles.