Ivonbrook Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. We found a positive culture within the service that focused on delivering person-centred care and support. Staff demonstrated a clear understanding of meeting people’s individual needs, preferences, and choices. Staff and relatives all spoke positively about the leadership of the service describing the management team as approachable, helpful, and visible within the service.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The management team demonstrated a good knowledge of the people who used the service and were passionate about ensuring the service delivered person centred care that met people’s needs. The provider demonstrated a commitment to supporting people with dementia and we found many initiatives in place to create a supportive, inclusive and dementia-friendly environment. For example, thoughtful adaptations, aids and activities which supported people to feel engaged and comfortable. Relatives also provided positive feedback about the care staff gave to people living with dementia, describing staff as “brilliant” and “genuinely caring”.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff confirmed to us they understood the provider’s procedures on speaking up and knew how to report any concerns they had. Staff told us they contributed their ideas about the service during meetings and supervisions. One staff member told us, “I have the freedom to express myself all the staff do, the managers encourage this.” We also found information on display advising people and visitors on how to raise any concerns they had.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff were supported through training and supervision to develop their practice and promote their understanding of equality, diversity and inclusion. The provider also fostered an inclusive culture through initiatives and events, such as a ‘Love is Love’ day, which celebrated diversity and encouraged acceptance. In addition, staff were given opportunities to experience aspects of living with dementia, helping them to develop a greater understanding of the challenges people may face. Staff spoke positively about this initiative and told us it had enhanced their understanding and influenced the way they delivered care and support.

Leaders had systems to oversee the quality and safety of the service, but these had not always identified areas where improvements were needed. As a result, governance processes did not consistently provide effective oversight of care planning and medicines management.

Systems and processes were in place to monitor the quality and safety of the service, including a programme of regular audits and checks. However, these systems had not always been effective in identifying and addressing issues found during the inspection. For example, audits had not identified inconsistencies within some care plans, or where care plans had not been updated to reflect changes in people's needs.

Medicines governance systems had also not identified that some 'when required' (PRN) medicine protocols lacked sufficient person-centred information to guide staff on when medicines should be administered, the signs and symptoms indicating their use, or alternative measures to consider before administration. In addition, medicines refrigerator temperatures had not always been maintained within the recommended range.

The provider took immediate action during the inspection to address these issues. However, the findings demonstrated that quality assurance and governance systems were not always effective in identifying gaps in care planning, record keeping and medicines management, this limited the management team’s ability to have full oversight of the quality and safety of the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The provider organised events teas and celebrations for where relatives and friends of people using the service were invited to attend. We also found evidence of effective collaboration with external agencies, including appropriate information sharing and engagement with external partners to support ongoing improvements in people’s care.

The provider promoted a culture of continuous learning and improvement across the service. Systems and processes were in place to identify opportunities for development, and staff spoke positively about the training, support and opportunities available to enhance their skills and career progression.

The provider reviewed and analysed information gathered through audits, meetings and feedback to drive improvements in the service. The provider demonstrated how feedback from people, relatives and staff was used to inform changes through their ‘You Said, We Did’ approach. Improvements made in response to feedback included warming plates prior to serving meals and making greater use of outdoor spaces to enhance people’s experiences and quality of life.