Archived: Ilsom House Care Home

Updated 9 June 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check 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 11 and 12 February 2016 and was unannounced. The inspection team consisted of two adult social care inspectors and a graduate analyst.

Prior to the inspection we looked at the information we had about the service. This information included the statutory notifications that the provider had sent to CQC. A notification is information about important events which the service is required to send us by law. We had a Provider Information Return (PIR) form. 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. We used this information to assess how the service was performing and to ensure we addressed any potential areas of concern.

We spoke with the registered manager, the deputy manager, three care staff, three nursing staff, the activity co-ordinator and a member of the catering staff. We spoke with six people who use the service and two relatives. We looked at information in seven care records, three recruitment records, staff training information, the duty roster and quality assurance records. We checked some procedures which included medicines and safeguarding adults. We also contacted a GP practice and healthcare professionals that visited the service to obtain their view of the service.

Updated 9 June 2016

This unannounced inspection took place on 11 and 12 February 2016.

Ilsome House provides nursing, residential, and respite care for up to 38 people. At the time of our inspection 27 people were living there. There was 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. There were no legal breaches of legal requirements at the last inspection in August 2013.

Medicine administration records were not maintained correctly to ensure safe practice and audits had not identified this. Not all storage was safe. Regular checks were made to monitor staff practice. People’s medicines were not consistently managed safely. This required improvement.

There was sufficient staff to meet people’s needs. Staff had completed regular training updates to ensure they had sufficient knowledge to carry out their roles. Staff had regular supervision meetings to identify staff training needs and monitor their progress.

People were kept safe by staff trained to recognise signs of potential abuse and they knew what to do to safeguard people. People and relatives we spoke with felt the home was safe and the service provided was safe. The recruitment procedures followed ensured people were cared for by staff who had appropriate checks completed before they started work and their practice was monitored.

People had access to health and social care professionals and were assisted by staff as required when they had appointments in the community. Visiting healthcare professional told us people were well looked after and staff responded quickly when required.

The staff were aware of people's dietary needs and preferences which were recorded in their care plans. The menus were based on the four seasons. The cook visited people in their bedroom or the communal areas to talk to them about their food preferences. Meal times were calm and unhurried and people at risk from malnutrition were monitored and supported to eat their meals. People told us about the food, “Food is marvellous and there is always a choice”, “Food is very good” and “I know I can have what food I want”.

Staff knew people well and were concerned for their wellbeing and responded to them in a caring way. People’s dignity was respected by staff and care plans described what people could achieve alone and when they needed assistance, this helped staff to promote their independence.

People had a range of activities they could be involved in. In addition to group activities people were able to maintain hobbies and interests. The activity programme was based on individual choices.

The service had robust quality assurance procedures which included the opinions of people and their relatives and action was taken to address improvements identified. Staff meetings were held and staff were able to influence any changes. Systems were regularly audited to improve the service.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.