Ivonbrook Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.The management team and provider ensured thorough investigations of accidents and incidents took place to determine the actions that may be required to reduce the risk of reoccurrence. The provider had systems in place to ensure accidents and incidents were regularly analysed for to identify any emerging themes or patterns to improve the care provided.

Systems were in place to support the safe monitoring and management of people’s care and health needs. While staff worked effectively with healthcare professionals to support people’s wellbeing, improvements were needed to ensure care records and monitoring documentation were consistently maintained and reflected people’s current needs.

Systems were in place to support the monitoring and management of people’s care. However, care plans were not always updated promptly to reflect changes in people’s needs, and some repositioning records contained gaps. This meant records did not always provide a complete overview of the care delivered or fully reflect people’s current needs. This reduced the provider’s ability to consistently demonstrate that people’s safety and care needs were being effectively monitored and managed.

Arrangements were in place to support people’s health needs, and staff worked with healthcare professionals to seek advice and guidance. Relevant information and recommendations were incorporated into people’s care plans to help support the delivery of coordinated care.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff had received safeguarding training and demonstrated a good understanding of their responsibilities for keeping people safe. Staff told us they had recently refreshed their knowledge of the provider’s safeguarding procedures and were able to explain the action they would take if they had concerns about a person’s safety or wellbeing.

Effective systems were in place to review, investigate and learn from accidents, incidents and safeguarding concerns. The management team responded appropriately to safeguarding incidents, including meeting their responsibilities under the duty of candour and making referrals to relevant external agencies, such as the local authority safeguarding team and the CQC where required. The provider monitored and analysed incidents to identify themes, trends and opportunities for learning, helping to ensure policies and procedures were followed consistently.

Information about safeguarding was readily available throughout the service, providing people, visitors and staff with guidance on how to raise concerns. The provider also shared safeguarding information through newsletters to help maintain awareness and promote a culture of safety.

The provider involved people and those important to them in discussions about managing risks and responding to changes in their needs. However, inconsistencies within some care records meant staff did not always have a clear and up to date overview of how risks should be managed.

People had care plans and risk assessments in place to identify and manage risks associated with their care and support needs. However, records were not always reflective of people's current circumstances. For example, some care plans contained conflicting information about people's mobility needs and the equipment required to support them safely. This increased the risk of staff not always having access to clear and up to date information when providing care.

We found one person had an identified risk which required ongoing monitoring and support, but there was no care plan in place to guide staff on how this should be managed. The provider took immediate action during our inspection to ensure appropriate care planning was implemented and staff had clear guidance on how to meet the person's needs safely.

Relatives spoke positively about how they were involved in managing risks and kept informed about changes to their family member's care. One relative told us, “Every time something has happened, they have got in touch, they have called the GP or paramedics. They are good at letting me know.” Another relative said, “We feel the risks are managed well.” One relative also described how they remained involved in reviewing their family member’s care, stating, “I’m involved in discussions, they do have the gateway system online, I look on it every couple of days.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had systems in place to ensure the environment was regularly checked for any potential hazards. We reviewed the health and safety within the service and found this was regularly checked and compliance certificates were in place and up to date.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staff were recruited safely. The provider followed safe recruitment processes to ensure people were suitable for their roles. This included undertaking appropriate checks with the Disclosure and Barring Service (DBS) and obtaining suitable references. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. We observed staffing levels throughout our inspection to meet people’s needs. Staff were attentive and responsive, often anticipating people's needs and demonstrating a good understanding of the people needs and preferences and treated people with kindness and respect.

The provider assessed and managed the risk of infection. The provider had systems and processes in place to ensure infection, prevention and control measures were regularly audited. We observed staff to follow the infection, prevention and control measures in place and staff had received training in this area.

The provider had established systems for managing medicines, but these were not always fully effective and required further development to ensure safe and consistent practice.

We found that 'when required' (PRN) medicine protocols did not always contain sufficient information to guide staff on when medicines should be administered, the signs and symptoms indicating their use, or alternative approaches that should be considered before administration. This meant staff did not always have clear, person-centred guidance to support consistent decision making. During the inspection, temperatures recorded for the medicine’s refrigerator were found to be outside the recommended range, however, the provider took immediate action to address this. While we found no evidence that these issues had resulted in harm to people, they indicated that medicines management systems required strengthening to ensure medicines were managed safely and consistently. Whilst improvements were needed in these areas, medicine stock balances corresponded with the records in place, staff had received training in the administration of medicines, and relatives consistently told us they had no concerns about how medicines were managed.