About the service: Ingleborough Nursing Home provides both nursing and personal care for people who may be living with dementia, a physical disability or be terminally ill. At the time of our inspection there were 34 people living at the home. Ingleborough Nursing Home is in the centre of the dales village of Ingleton, local amenities are easily accessed.

People’s experience of using this service: People did not always receive a service that provided them with safe, effective and high-quality care. The management of people’s medicines was not safe. Risk management was ineffective and potentially placed people at risk of harm. Some infection control practices were not effective.

Staff had not completed all mandatory training and supervision was not conducted in line with the provider’s policy. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; however, some systems did not support this practice. The home had undergone some refurbishment, but other areas of the home were dated and did not fully provide a dementia friendly environment.

Care plans were mostly person-centred but they had not always been consistently updated and reviewed to ensure they reflected people’s current needs. The service had a quality assurance system in place but this was not always effective. Accidents and incidents were not analysed and some people’s records were not kept securely.

People had access to a comprehensive range of activities and the provider worked with other organisations, to meet people’s needs. Staffing numbers were sufficient and the provider followed safe recruitment procedures. Staff understood how to identify and report any safeguarding concerns.

People told us staff were kind and caring and people’s dignity and privacy were respected. People received enough to eat and drink and were supported to use and access other healthcare professionals.

The culture of the service was open and people felt able to raise any issues. People and relatives had the opportunity to provide feedback on the service received and there was a system to respond to any complaints. People and their relatives were supported to receive information in an accessible way to enable them to be involved in their care and support. The registered manager was aware of their responsibility to report events that occurred within the service to the Care Quality Commission (CQC) and external agencies.

For more details, please see the full report below which is also on the CQC website at www.cqc.org.uk

Rating at last inspection: At the last inspection the service was rated Good. (report was published 6 September 2016). The rating has deteriorated to Requires Improvement at this inspection.

Why we inspected: This was a planned inspection based on the rating at the last inspection. All services rated ‘good’ are currently re-inspected within 30 months of our prior inspection.

Enforcement: We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 namely safe care and treatment and good governance. Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up: We will continue to monitor the service through information we receive. Further inspections will be planned for future dates as per our re-inspection programme. If any concerning information is received we may inspect sooner.

This inspection took place on 14 July 2016 and was unannounced.

At the last inspection carried out on 2 February 2015 the provider was meeting all the regulations that were assessed.

Ingleborough Nursing Home provides residential and nursing care for up to 55 older people, some of who are living with dementia. On the day of the inspection there were 37 people living at the service, 24 of whom required nursing care. Some people living at Ingleborough had a diagnosis relating to dementia but the service did not offer specialist dementia services.

Ingleborough Nursing Home had a registered manager in place. 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.

Staff had been employed following safe recruitment and selection processes

People were protected from avoidable risks and staff were aware of their duty of care to the people. Staff were trained to recognise and respond to signs of abuse. Risk assessments were carried out and reviewed regularly.

The home had safe systems in place to ensure people received their medication as prescribed; this included regular auditing by the home and the dispensing pharmacist. Staff were assessed for competency prior to administering medication and this was reassessed regularly.

Staff had appropriate training, supervision and support, and they understood their roles and responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

There was a variety of choices available on the menus, snacks were freely available throughout the day and people were supported to have sufficient food and drinks to meet their dietary needs.

Staff were caring, kind and compassionate and cared for people in a manner that promoted their privacy and dignity. People felt listened to and had their views and choices respected.

People were involved in activities they liked and were linked to previous life experience, interests and hobbies. Visitors were made welcome to the home and people were supported to maintain relationships with their friends and relatives.

People knew how to make a complaint if they were unhappy and all the people we spoke with told us that they felt that they could talk with any of the staff if they had a concern or were worried about anything.

The provider actively sought the views of people using and visiting the service. They were asked to complete surveys; this enabled the provider to address any shortfalls and improve the service.

People were involved in the decisions about their care and their care plans provided information on how to assist and support them in meeting their needs. The care plans were reviewed and updated regularly.

The service had a quality assurance system, and records showed that identified problems and opportunities to change things for the better had been addressed promptly. As a result we could see that the quality of the service was continuously improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and the quality assurance systems in place. This helped to ensure that people received a good quality service. They told us the registered manager was supportive and promoted positive team working.

As part of this responsive follow up inspection we spoke with the provider, the deputy manager, and two members of staff, one visitor and one person who lived in the home. We did this to take account of the views of people living and working in Ingleborough nursing home. This helped us to gain a balanced overview of what people experienced living and working in the home. At the time of this inspection the registered manager was away on holiday.

During this inspection we looked at the environment of the home; and maintenance and risk assessment records. We found from the inspection the provider had addressed the issues and concerns identified at the previous inspection in August 2014.

Is the service safe?

One person we spoke with told us they were happy living in the home. They told us felt they could raise any concerns they may have regarding their room with the staff. A visitor told us they had no concerns regarding the environment and the bedroom of their relative. They did comment on the condition of the lift in the home, which they considered was unsuitable due to its size. However when we spoke with the provider, they told us they were currently in the process of purchasing a new platform lift. The installation of a new platform lift was part of their general refurbishment and upgrading of the facilities within the home. This is to improve access to the cottage and garden area of the home. The new platform lift will be accommodated in an area of the home that has been designated for this use as part of the reorganisation of the laundry.

When we inspected the laundry room, we found the provider had taken action to manage the risks posed to people when working in the laundry. One staff member commented, “I am really happy with the changes in the laundry room. The new flooring is a big improvement. It is easier to keep clean”.

Is the service effective?

Since the last inspection the provider had recruited an additional maintenance person to assist with aspects of more specialised work required in the home. It was evident during our inspection that remedial and upgrading works were taking place in the home.

Is the service caring?

We observed staff to speak with people in a caring way. We saw people were treated with respect and dignity. People`s bedrooms reflected their individual tastes and were decorated in homely way.

Is the service responsive?

Maintenance records had been reviewed and improved upon since the last inspection. There was a daily task list in place which prioritised areas of work for the maintenance team to undertake. It was a requirement that the task list was signed by the maintenance staff once completed. This was to ensure repairs and regular safety checks were undertaken in a timely way.

Is the service well-led?

Since the last inspection the provider had acknowledged the shortcomings we had identified with the environment and had undertaken an audit across the home. As a result they had made a decision to undertake upgrading and refurbishment of the facilities within the home. This included extending the laundry and relocating it onto single floor accommodation. They had plans to replace old equipment such as the lift, and to upgrade one of the bathrooms on the ground floor to provide a wet room facility. The provider now undertook direct oversight and management of the environment to ensure that any shortfalls would quickly be addressed and remedied. We saw building works and refurbishment work taking place. The provider of the home had taken responsibility to regularly monitor and audit the completion of works to ensure work is carried out in a timely way.

At the time of our inspection the registered manager was away on holiday. During this inspection we spoke with the nominated individual, the Deputy Matron, two care staff, a laundry worker and three people who lived at the home. In addition we spoke with a GP, a GP Registrar and a district nurse.

We considered all the evidence we had gathered under the outcomes we inspected.

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

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

Is the service safe?

We saw there were robust systems in place to assess and check appropriate and safe care was being delivered. These included daily and monthly internal audits. These audits included infection control and prevention and the quality of care plans.

The provider had appropriate security arrangements in place to protect people who lived at the service. We found that the entrance door was secure and visitors could only enter the building with the knowledge of the staff. People told us they felt safe and secure in the home.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We were told that one person using the service was subject to authorised deprivation of liberty. We found that the requirements of the Mental Capacity Act 2005 deprivation of liberty safeguards and imposed conditions in the authorisation were being met.

We saw that appropriate arrangements were in place to ensure people taking medicines which required specific monitoring procedures could do so safely.

We found some areas of the home posed a risk for people. Some high surface temperature radiators were not covered to prevent injury to vulnerable people. We found damage to some wooden structures posed a risk from splintered wood and exposed nails. We also found the laundry to be poorly maintained and of poor design which exposed staff to the likelihood of trips and falls.

Is the service effective?

People told us the care they received met their needs. Our scrutiny of care plans demonstrated to us that relatives had been involved in planning the care people received. We asked people if they liked living at the home and they told us that they did. One person said, "I am comfortable here especially since my bedroom was decorated".

Staff with whom we spoke were clear about the needs of the people they supported and what they told us was reflected in people’s care plans.

We spoke with staff who told us they felt well supported by the manager who ensured access to regular training and development.

Is the service caring?

We saw staff treated people with dignity and respect and maintained their privacy and dignity. We heard care staff speaking courteously and kindly with people, asking permission before helping to support them and explaining what was happening. We observed care staff supporting people where needed in a calm and unhurried manner.

During our visit we saw the atmosphere was calm and relaxed. People appeared comfortable and were well dressed and clean, which demonstrated staff took time to assist people with their personal care needs. This showed us staff treated people who lived at the home with compassion and respect and encouraged them to retain their independence wherever possible.

Is the service responsive?

Care and support was provided in accordance with people's preferences, interests and diverse needs. Records we looked at, discussion with staff and observations showed that people's wishes were respected and acted upon.

We saw some people easily interacting with others whilst some preferred to sit alone. Many people said very little and some lacked motivation but staff were observed giving encouragement on a one-to-one basis.

We found that when people required care and treatment from another provider, such as a dentist or optician, the provider obtained these services in a timely way. We spoke with a GP and a GP Registrar who were visiting the home. The GP spoke in a positive way describing the service as good with excellent communications between the staff and the GP practice.

Is the service well-led?

We found the service had an effective quality assurance system in place and any identified actions had led to improvements in the care that people received.

Decisions about care and treatment were made by the appropriate staff at the appropriate level. Staff said they felt the service was well-managed and the registered manager was approachable and enthusiastic. They said they had confidence that any issues brought to their attention were always dealt with properly and thoroughly.

We found that the provider was delivering the frequency of staff supervision and appraisals as set out in its own policy.

Staff told us they were clear about their roles and responsibilities. Staff told us the leadership at the service was inclusive and their views were taken into consideration.

We did however find that the provider was not addressing known shortfalls in their approach to maintenance issues.

Some people were not able to tell us about their experiences. We therefore used a number of different methods to help us to understand the experiences of people, including observing the delivery of care. We talked to those people who were able to share their experience and we also spoke with four visitors. Everyone we spoke with told us they were satisfied with the care they or their relative received.

People told us they felt well cared for. They made comments such as, “All the staff are very caring.” And “The staff are very gentle and considerate when helping me.” Without exception, people and their relatives gave us the impression that their experiences at the service were positive and that they received a good standard of care.

We looked around the home and saw that the home was clean and well maintained. We observed the home was fresh and free from odour.

We looked at the medication and found the systems for helping people to manage their medication were safe and well organised.

We also found that staff were well supported. This included regular supervision and staff meetings. Staff also had regular training and development opportunities.

We confirmed that regular checks were carried out by the provider and manager, to monitor the quality of the service and that the service annually reviewed people’s ‘satisfaction’ of the service. We also saw that there was an effective complaints system.

We visited the home to look at outstanding compliance actions that we made on our visit in August 2012. The concerns we had were that people were not always properly consulted and that people who lacked capacity did not have the right support in place to make ‘best interest’ decisions about their care. We also found record keeping was subjective and not audited consistently.

On the last visit we also found improvements were needed to the environment. Areas of the home needed refurbishment and the storage of hazardous substances needed to be safely controlled. The provider wrote to us and told us they had a plan to address our concerns. They told us they would complete the work by December 2012.

We found at this visit that improvements had been made and the provider, registered manager and staff had worked hard to improve the standards in the home. We found the capacity assessments and agreements were in place when important decisions were made. We also found that care records overall had improved. We also saw the environment had improved, areas had been redecorated and clearer signage had been put in place to aid people to recognise areas of the home. The toilets had been extensively refurbished, chemicals were now being stored in a safe locked area and repairs and been completed.

We were not able to communicate with some people due to their complex communication needs, but through observations they appeared relaxed and comfortable. We did however speak with five people who told us that they were happy living there and that they were supported to make choices in their daily routines, according to their wishes.

We spoke to two visitors who were also happy with the care provided to their relative and told us that they visited regularly and the care was consistently good.

People told us that that they felt there were enough staff on duty, and that the staff were very attentive to their needs. They also told us that when required they used the nurse call bell to summon help. They said that the staff responded quickly and that this made them feel reassured.

People told us that they were well looked after and that they were happy with the care they received. One person commented, ‘yes it is fine here the staff are good they are all helpful and they respect me.’ Another person said 'We are well looked after. The home is grand can’t fault it at all. Staff are champion, grand lot of lassies here.’ However another person said, ‘It is all right here, we could do with some more staff especially in the evenings when you want to go to bed.’

People living at the home were also positive about the food. They made comments such as ‘the food is good’ another person said, ‘The food is very good here I would recommend it’ another person said ‘the food is good and we have a choice of menu.’

We also talked to a number of relatives who were visiting the home. All of the relatives spoke highly about Ingleborough. Relatives made comments such as ‘The home is well run and efficient. The staff are very approachable and caring. They are very good at following up on everything.’

Relatives also made comments about the environment such as ‘The home is lovely. Mum has settled and it is so clean, the domestic staff do a good job.’