Hope Valley Nursing Home

This assessment was carried out in response to information of concern received.

The provider was in breach of 3 legal regulations relating to good governance, safe care and treatment, staff training and person-centred care at the service.

The provider did not have a proactive learning culture. Accidents, incidents and falls were not robustly reviewed or analysed to improve safety. This also meant safeguarding concerns were not always promptly identified. Risk assessments identified and assessed risks to people but required more timely reviews as people’s needs changed. Medicines were not safely managed, and we found discrepancies in medicine stock during our first site visit which meant we could not be assured medicine was always administered as prescribed. Staff were not suitably trained to carry out their roles safely. Whilst we observed safe staffing levels, we received mixed feedback on staffing levels at the service.

Improvements were required to ensure people, and those important to them, were involved in the care planning process. Records did not always demonstrate care was delivered consistently in line with assessed needs. Clinical monitoring of health and well-being was not always effective. Care plans required further improvement to ensure they were fully person-centred. End of life care planning was insufficient. We identified some limited accessibility within the service such as poor lighting and signage, however people had access to walking aids.

Governance systems were not effective at identifying risks to safety and quality of care. The provider failed to follow their own policies to ensure a safe and effective service. The provider worked with relevant stakeholders to drive improvement. However actions were often reactive rather than proactive due to lack of own internal quality assurance systems. Although the provider took some immediate actions following our first site visit, such as completing a full medicine stock count, many planned improvements had not yet been embedded at the time of our inspection. As a result, we were unable to evaluate the effectiveness of these actions.

People were supported to access relevant healthcare professional support, and the provider followed the principles of the Mental Capacity Act (2005). Staff were observed to be responsive to requests for support during our inspection, although systems to monitor responsiveness were lacking. Staff felt supported in their roles and the provider promoted staff well-being. The provider was working to promote an inclusive culture within the workforce.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

We have asked the provider for an action plan in response to the concerns found at this assessment.