This comprehensive inspection took place on the 25 June 2018 and was unannounced.

We carried out an unannounced comprehensive inspection of this service on 1 March 2017. The service was rated 'Requires Improvement'. Four breaches of legal requirements were found. One breach related to safe care and treatment. After the comprehensive inspection, we used our enforcement powers and served a Warning Notice on the provider for this breach on 7 April 2017. This was a formal notice which required the provider to meet the legal requirements by 5 May 2017. Following the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook a focused inspection in July 2017 to follow up the breach detailed in the Warning Notice and to confirm that they met legal requirements . At the focused inspection we found that the provider was still not meeting the legal requirements . We asked the provider what action they took already following the feedback they were given after the inspection and asked how they plan to meet legal requirements.

The breaches previously identified in the last comprehensive inspection in March 2017 were followed up as part of this inspection. You can read the report from our last inspections, by selecting the 'All reports' link for Ivybank House Care Home, on our website at www.cqc.org.uk. The service remains rated as requires improvement.

Ivybank House Care 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. Ivybank House is registered to provide accommodation for up to 43 older people who require nursing and/or personal care.

Accommodation is provided on the first and second floors, accessed by a lift. Communal areas such as dining rooms and lounges are situated on both floors of the service. At the time of the inspection, 28 people were living at the service.

At the time of this inspection, the service was being managed by a newly appointed manager supported by the deputy manager, regional support manager and regional manager . The previous registered manager had left the service at the end of May 2018 and prior to the new permanent manager being appointed, two different registered managers from the providers other services had supported the deputy manager and the staff team.

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, we found that staff were not supported to undertake training to enable them to fulfil the requirements of their role. We found that whilst staff told us there had been an improvement in training provision, some staff had not had training other than provider’s statutory updates for some months .

At our previous inspections, in January 2016, March 2017 and July 2017, we found that medicines were not always managed safely We found the management of medicines required further improvement to ensure medicines were handled and received safely.

At our last inspection in July 2017 lack of monitoring meant there was a risk that people might not have enough to eat or drink. At this inspection, we found that this had improved and people that were at risk from malnutrition and dehydration were now being monitored effectively.

At our last inspection in March 2017, we found the quality and content of care plans was variable. Although some were well written, with clear guidance for staff to follow, this was not consistent. We saw that some people's care plans had been rewritten and/or updated since our last inspe

This inspection took place on 8 July 2017 and was unannounced.

We carried out an unannounced comprehensive inspection of this service on 01 March 2017. The service was rated ‘Requires Improvement’. Four breaches of legal requirements were found. One breach related to safe care and treatment. After the comprehensive inspection, we used our enforcement powers and served a Warning Notice on the provider for this breach on 7 April 2017. This was a formal notice which required the provider to meet the legal requirements by 5 May 2017. Following the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook this focused inspection to follow up the breach detailed in the Warning Notice and to confirm that they now met legal requirements. This report only covers our findings in relation to this legal requirement.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ivybank House Care Home on our website at www.cqc.org.uk”

Ivybank House Care Home is registered to provide accommodation and personal care for up to 43 people. At the time of our inspection there were 34 people living at the service.

There is a registered manager in post. 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.

Medicines were not managed safely. Some records contained conflicting information about medicines people were allergic too. Medicines were not always stored safely.

Risks to people were not always managed safely. Risk assessments were not always updated when required. People’s records showed they were not repositioned in line with their care plans. One person was not supported to drink amounts identified as appropriate for them. People were not weighed in line with their identified needs.

Staff received training in safeguarding vulnerable people, but did not fully understand their responsibilities around reporting abuse.

People told us there were sufficient staff to meet their needs.

There were suitable recruitment procedures and required employment checks were undertaken before staff began to work at the home.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

This inspection took place on 1 March 2017 and was unannounced. The last full inspection took place in January 2016 and, at that time, one breach of the Health and Social Care (Regulated Activities) Regulations 2014 was found in relation to safe care and treatment. This breach was followed up as part of our inspection. The service was rated ‘Good.’

Ivybank Care Home is registered to provide accommodation and personal care for up to 43 people. At the time of our inspection there were 35 people living at the service.

There was no registered manager in post at the time of inspection. 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. The current manager has been in post since December 2016. They told us that they intend to process their registered manager’s application form.

Since the previous inspection in January 2016 there have been two changes of home manager. The high turnover of home managers has affected the level of service. The provider had failed to fully implement the actions in their plan from the previous inspection to ensure they were no longer acting in breach of the regulations. As well as not implementing the stated actions in the plan we found further breaches of the regulations.

Medicines were not managed safely. The senior carer responsible for medicines did not know about the specifics of administering some medicines.

Risks to people using the service were not in all cases managed appropriately. Risk assessment plans were not always up-dated when required.

Staff were not consistently supported through an effective training and supervision programme.

People's records were not always monitored to manage their health conditions. Some people were having their food and fluid intake monitored because they had been assessed as being at risk of dehydration or malnutrition. Although recorded fluid intake was not consistently totalled and it was not clear whether concerns were escalated.

Care plans were not consistently written in conjunction with people or their representative. Some people had little understanding of their care planning and some told us that they had never seen their care plan.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. At the time of the inspection no one was subject to a DoLS authorisation. The manager demonstrated an understanding of the procedures that needed to be followed to apply for a deprivation of liberty, if required.

Staff in the main understood their responsibilities with regard to safeguarding people from abuse.

People told us that the staff were kind and caring. Staff were knowledgeable about people's needs and told us they aimed to provide personalised care to people. Staff told us how people preferred to be cared for and demonstrated they understood the people they cared for. They were aware of people’s personal histories and interests.

People had access to a wide range of activities. They included; yoga, music, tea and a natter, a reading group, hand massage and relaxation, knit and a natter, gentle exercise to music, a sewing bee and a range of one to one activities. Peoples’ spiritual needs were met. Services were held at the service twice a week.

Relatives were welcomed to the service and could visit people at times that were convenient to them. People maintained contact with their family and were therefore not isolated from those people closest to them.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2

This inspection took place on 5 January 2016 and was unannounced. When the service was last inspected in June 2014 there were no breaches of the legal requirements identified.

Ivybank Care Home is registered to provide accommodation and personal care for up to 43 people. At the time of our inspection there were 36 people living at the service.

There was no registered manager in post at the time of inspection. 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. The current manager has been in post since December 2015. They told us that they intend to process their registered manager’s application form.

Medicines were not always managed so that people received them safely because controlled medicines were not being managed safely. Controlled medicines are controlled under the Misuse of Drugs legislation. Stricter legal controls apply to controlled medicines and govern how controlled medicines can be stored, produced, supplied and prescribed. Controlled medicines were not being stored safely because stock balance controls were not being maintained by staff, which meant it was not always clear how much of a medicine was in stock.

Staff were not consistently supported through an effective training and supervision programme. The new manager told us they were aware of this position. They provided evidence that plans are in place to ensure the training compliance rates and regularity of supervisions will improve.

People were generally cared for in a safe, clean and hygienic environment. During the inspection concerns were raised about the kitchen and these were largely taken forward on the day of the inspection.

A range of checks had been carried out on staff to determine their suitability for employment. Staff we spoke with demonstrated a good understanding of how to recognise and report suspected abuse. Staffing levels were maintained to a sufficient level to keep people safe.

People had their physical and mental health needs monitored. All care records that we viewed showed people had access to healthcare professionals according to their specific needs.

People spoke positively about the staff and told us they were caring. One person told us, “The staff are nice. They’re all helpful. They discuss what I need.” Staff told us they aimed to provide personal, individual care to people.

Relatives were welcomed to the service and could visit people at times that were convenient to them. People maintained contact with their family and were therefore not isolated from those people closest to them.

The overall feedback about the service and the new manager had been positive. Staff spoke positively about the manager. People were encouraged to provide feedback on their experience of the service and the manager had systems to monitor the quality of service provided.

We found one 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 this report.

A single inspector carried out this inspection. This was a scheduled inspection where we also followed up improvements which were required in outcome 21 record keeping.The focus of the inspection was to answer five key questions; is the service caring, responsive, safe, effective and well-led?

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

During the inspection we spoke with 13 people who used the service, two relatives, the registered manager, care team leader, three care staff, the chef and kitchen assistant, the dining room hostess, the maintenance person, housekeeping and the activities organiser.

This is a summary of what we found:

Is the service caring?

People looked well cared for. When we spoke with people and relatives they were very complimentary about the care and support they received. We observed that all staff were respectful towards the people who lived in the home and people confirmed this.

Staff were knowledgeable about the people they cared for and knew people's likes and dislikes and their preferred care routines. One relative told us that they thought the care their family [two people] received had been ‘excellent’.

Is the service responsive?

The home provided services for people with varying levels of needs and records clearly demonstrated how care and support should be provided in line with people's wishes.

People's care and treatment was reviewed on a regular basis with them; this enabled people to discuss any changes or preferences regarding their care and support.

People took part in activities if they wished to. The activities co-ordinator consulted people about their interests and hobbies and the activities they would like to see in the home.

Is the service safe?

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found there were appropriate policies and procedures in place and staff had been trained to understand when an

application should be made.

People had access to safe and appropriate equipment to promote and maintain their independence, such as walking frames and wheelchairs. The manager ensured that people had safe equipment and where necessary made a referral to external agencies to support this. The communal areas within the home were clutter free; this supported people to move around the home safely and freely.

Is the service effective?

The home had systems in place to ensure that people received the care they required. The care plans were person centred and demonstrated that people's care and treatment needs had been assessed and were reviewed on a regular basis. The care staff worked closely with other health and social care professionals to ensure that they had the relevant guidance when care and support needs changed.

The chef liaised with care staff in devising specialist diets or when dietary needs changed. People said they were happy that they received appropriate care and support.

Is the service well-led?

There were quality assurance processes in place which were monitored externally through the provider. There were audits in place and checks were made regarding the environment, staff supervision and training, record keeping, infection control, medicines, falls risks and complaints. People told us they would inform the manager if they had any complaints. On the day of our inspection some people told us they did not feel there were adequate staffing levels at all times. We spoke with the manager about this and they told us they would investigate this further.

People were asked for their opinion on the service they received through a customer satisfaction survey. Staff were able to discuss concerns directly with the manager or through team meetings. Staff were aware of the structures in place regarding accountability and were confident in their role and responsibilities.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. One person said that staff were ‘supportive’.

People were provided with a choice of food and drink which met their individual needs and they were supported by staff to eat and drink. One person said that food and drink arrangements were ‘very good on the whole’.

The provider had taken appropriate steps to ensure that there were sufficient numbers of appropriately qualified staff to meet people’s needs.

The provider had an effective complaints system. People at the home said that they would feel able to speak to a member of staff if they had any complaints.

Records were accurate and detailed. However, they were not always kept securely and the manager was not aware of guidance relating to how long records should be retained.

We spoke with four people who lived at the home and one person who had once weekly respite care. These people said overall the food was good. One person said the food was “cracking” and another person said the quality of the food fluctuated at times but that consistency was difficult on such a scale.

The people we asked said their privacy and dignity was respected. They told us who helped them make decisions about their care and treatment. One person told us their daughter helped them make big decisions but they made day to day decisions such as what to eat or what to wear. Another person said: “certainly I make my own decisions and choices.”

We were told the staff sat with people to discuss how they wanted their care needs to be met. People said they had access to a GP and had regular check-ups.

People said they felt safe when they were alone with the staff and would approach the deputy or manager with complaints. One person said they felt confident that their concerns would be acted upon.