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Archived: Ivydene Care Home

Overall: Requires improvement read more about inspection ratings

Ivydene Close, Earl Shilton, Leicester, Leicestershire, LE9 7NR (01455) 843001

Provided and run by:
Ivydene Care Home Limited

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Background to this inspection

Updated 17 November 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.

The inspection visit took place on 6 October 2016 and was unannounced. The inspection team included an inspector and an expert by experience (ExE). An ExE is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection visit, the provider completed a Provider Information Return (PIR). 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 also reviewed the information that we held about the service to plan and inform our inspection. This included information that we had received and statutory notifications. A statutory notification contains information relating to significant events that the provider must send to us. We also contacted Healthwatch (the consumer champion for health and social care) and the local authority who has funding responsibility for some people living at the home to ask them for their feedback about the service.

We spoke with four people who used the service and with the relatives of three other people. We spoke with the registered manager, the deputy manager, three care staff and a cook. A health care professional was visiting the home when we visited so we spoke with them to gain their feedback on the service offered. We observed staff offering their support to people throughout our visit so that we could understand people’s experiences of care.

We looked at the care records of three people who used the service. We also looked at records in relation to people’s medicines, health and safety as well as documentation about the management of the service. These included policies and procedures, training records and quality checks that the provider had undertaken. We looked at three staff files to look at how the provider supported their employees and how they had recruited them.

Overall inspection

Requires improvement

Updated 17 November 2016

We carried out an unannounced inspection visit to the service on 6 October 2016. This meant that the registered manager and provider did not know we would be visiting.

Ivydene Care Home provides care and support for up to 23 older people. At the time of our inspection 18 people were using the service many of who were living with dementia. The accommodation was offered over two floors. There were two communal lounges and two dining areas.

At the time of our inspection there was a registered manager in place. It is a requirement that the service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 provider had not always followed their policy and local safeguarding guidance when responding to suspected or actual abuse. This meant that the police and local safeguarding team were not able to investigate concerns at the time they occurred.

People were not always supported in line with the Mental Capacity Act 2005 (MCA). The provider had not assessed people’s mental capacity to make specific decisions where this was necessary. Decisions had not always been made in people’s best interests. This meant that people may have received care that was not in their best interests. The registered manager told us they would complete the assessments. We saw that some people had restrictions placed upon them as they were not able to go out independently and may not have had the capacity to make a decision about their safety. Applications to ensure these restrictions were lawful were made to the local authority. Staff understood their responsibilities under the MCA and sought the consent of people when delivering care.

The provider did not meet the requirements of their registration with CQC. The provider did not always submit statutory notifications to CQC following significant incidents at the home as required by law. We also found that the provider did not display their rating from the latest CQC report. This is a legal requirement to inform people about our judgement about the quality of the service provided. The provider told us they would make sure the rating was displayed within the home and on their website.

Staff members understood their responsibilities to protect people from harm and to remain safe. We saw that the provider had a system to manage accidents and incidents. However, the analysis and investigation of these by the registered manager was not always recorded. This meant that there was a risk that measures put into place to help people to remain safe were not always monitored to check their effectiveness when an incident occurred. The registered manager told us they would use their incident forms more thoroughly in the future to detail their investigations.

People told us they felt safe. However, we saw there were some risks to people’s health and well-being. This included equipment stored against a fire door. The provider told us they would remove the items. We saw that the provider had plans in place to keep people safe during emergencies such as a fire. The provider also regularly checked the safety of the environment and equipment to reduce risks to people’s safety.

People’s care records did not always detail their specific health care requirements to support them to maintain their health. For one person there was no guidance for staff about what constituted a suitable blood sugar level for them to determine if the advice of a health professional should be sought. The registered manager told us they would make improvements to people’s care records. People had access to regular health care professionals to maintain their health including their GP.

People did not always receive care when they required it. For example, some people spent periods of time without staff enquiring if they wanted to engage in an activity or if they required support. The provider had not adapted the environment to be responsive to people living with dementia such as having clear signs to help people know where they are.

People and their relatives were not satisfied with the amount of activities offered to them. On the day of our visit some activities were occurring including one-to-one activities with people. The provider had displayed a notice asking relatives for activity suggestions.

The provider’s quality checks were not always suitable to ensure people received good care. We found concerns during our visit that were not identified by the provider’s own audits. These included the provider not always notifying the correct authorities following significant incidents.

People were involved in decisions about their care wherever possible and information on advocacy services were made available to help them to speak up where this may have been required. People were supported to be as independent as they wanted to be in order to retain their skills and abilities. People or their representatives had opportunities to contribute to the planning of their care where they were able to. People’s care plans were regularly reviewed but did not always contain information specific to all areas of their care requirements.

The provider had a suitable recruitment process in place for prospective staff which included relevant checks. People, their relatives and staff felt there were enough staff to offer safe care. We found staffing numbers to be appropriate to meet people’s needs safely.

People received their prescribed medicines in a safe way at the time they required them. Staff recorded the administration of people’s medicines and handled them in line with national medicines guidance. We saw that staff were trained in the safe handling of medicines and their competency was due to be checked by the registered manager to make sure they continued to have the required skills and knowledge.

People received care from staff who received regular training and guidance on their work. Staff undertook training in topic areas such as assisting people to move and in fire safety. New staff received an induction when they started working for the provider so that they were aware of their responsibilities. Staff members also met regularly with a manager so that they could gain feedback on their work.

People were satisfied with the food and drink available to them and mealtimes were relaxed. Their likes and dislikes were known by staff. Where there were concerns about people’s eating and drinking, specialist advice had been sought and incorporated into the support that staff offered. This included modifying people’s diets where this was required to support people to maintain their health.

People received support from staff who were kind and compassionate. Staff protected their dignity and privacy by, for instance, closing dividing curtains within shared rooms when delivering care. Staff knew the people they supported including their preferences and life histories. People’s care records were stored safely in line with the provider’s policy to maintain their confidentiality. People and their relatives told us that visitors were made welcome and could visit without undue restriction.

People’s relatives knew how to make a complaint should they have needed to. The provider had a complaints policy in place which was displayed so that visitors knew the process. The provider had not received any complaints in the last 12 months.

People, their relatives and staff felt that the service was well-led and had opportunities to give feedback to the provider. Staff felt supported by the registered manager and they were aware of their responsibilities. They knew how to report the inappropriate or unsafe practice of their colleagues should they have needed to.

We found four breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 and of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report.