Archived: Ivy House

Updated 16 February 2017

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 was 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.

This inspection took place on 6 December 2016 and was unannounced. The inspection team included an inspector, an expert by experience (ExE) and a specialist professional advisor (SPA). An ExE is a person who has personal experience of using or caring for someone who uses this type of service. The SPA had a nurse background which included experience of dementia care.

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. As part of our planning we reviewed the information in the PIR. We also reviewed the information we held about the service, which included notifications. Notifications are changes, events or incidents that the registered provider must inform CQC about.

We spoke with the local authority commissioning team. Commissioners are people who work to find appropriate care and support services which are paid for by the local authority.

We spoke with eight people who used the service and used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk to us. We also spoke with one relative, the registered manager, the deputy manager, one care staff and the activities care co-ordinator.

We reviewed records which included three people’s care records to see how their care and treatment was planned and delivered. We reviewed three staff employment records and other records which related to the management of the service such as quality assurance, staff training records and policies and procedures.

Updated 16 February 2017

This inspection took place on 6 December 2016 and was unannounced. At our previous inspection during November 2013 the provider was meeting all the regulations we checked.

Ivy House is registered to provide residential care for up to 22 older people. At the time of this inspection some people were living with dementia. The service was providing support for 17 people at the time of our inspection.

There was 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.

We found that the leadership and management of the service and its governance systems were not robust. Systems to monitor and review the quality of some areas of the service people received were not effective and therefore we found a number of areas that required improvement.

At this inspection we identified environmental risks for people who lived at Ivy House. These included an external door not being locked, which provided unauthorised access into the service. This also meant people who lacked road safety awareness due to their health condition, could leave the service without supervision. We saw that some furniture in the main dining lounge was damaged, which made it unsafe for people to use.

We identified shortfalls with the management of medicines. This included medicines not being stored securely. We saw the medicines fridge was not locked, as well as the cupboard where this was stored. This meant medicines could be accessed by unauthorised people who were not prescribed them.

Our observations showed that staff did not always respect people rights to make their own decisions when possible.

We observed a person carrying a walking frame whilst using the stairs. This showed that the level of risk had not been considered by the provider to avoid injury to the person and others including staff.

We saw staff were not suitably deployed. Our observations showed staff were not always present in communal areas which meant people did not always get the support they required. For example we saw one person pushing their zimmer frame into another person as they were frustrated with the other person’s behaviour.

Recruitment procedures were not thorough. Staff recruitment records showed that a full employment history was not always in place.

We saw insufficient evidence regarding the training that staff had undertaken. The provider did not have effective systems to monitor training staff had undertaken or waiting to be completed, to enable them to do their job effectively.

Staff gained people’s verbal consent before supporting them with any care tasks. However the provider did not have effective procedures for staff to follow in relation to the Mental Capacity Act (MCA) 2005. We saw that were people lacked capacity, mental capacity assessments had not been completed and staff had not undertaken training on the MCA

The needs of people living with dementia were not fully met because people’s social and therapeutic needs were not addressed. People and their relatives were not always involved in planning and agreeing on how they were supported. This did not ensure people received personalised care.

People who used the service told us they felt safe. Staff we spoke with understood their responsibility in protecting people from the risk of harm. People told us that staff treated them in a caring way and respected their privacy and supported them to maintain their dignity.

People enjoyed the food and drink they were served. People were supported at mealtimes if they required this. Arrangements were made for people to see the GP and other healthcare professionals as and when they needed to.

We found a 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 the report.