Ivy House Residential 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.

This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to consent, safe care and treatment and recruitment.

This service scored 38 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Actions to reduce the risks of incidents reoccurring were not always effective. Records showed a contributing factor to a person’s fall had reoccurred, despite actions being initially identified to reduce this risk. The section on the incident reporting form to confirm a manager had reviewed any incidents and to confirm if the incident was preventable, or whether any further investigation and actions were needed had not always been completed. This meant the provider could not always demonstrate how they would prevent similar issues from happening again, as they had not identified and learnt lessons from previous outcomes.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

Records showed other healthcare partners had not always been contacted in a timely manner for advice, for example, following a person’s fall. We made a safeguarding referral so this could be considered. This meant advice from healthcare professionals had not always been included and considered when decisions were taken on how to maintain and monitor people’s health.

However, people spoke positively about their move to live at Ivy House Residential Care Home. One relative told us, “Initially [name of person] came here for two weeks respite. We weren’t coping at home and a friend recommended here. It’s near to where we live and staff got to know [person] really quickly, so it just made sense for them to stay.” Another person said, “I was living at home but had some falls. My [relative] had visited the home to see someone else and thought that I would like it here. So I came to visit and the decision was made very quickly. It was the right one. I’m very happy here.”

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People’s rights had not always been considered in line with the Mental Capacity Act 20025 and the Deprivation of Liberty Safeguards. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. The registered manager told us all but 1 person had the capacity to understand their care decisions. However, records and further discussions with staff showed more people could not reliably understand how and why aspects of their care were being provided in the way it was. These decisions had not been assessed, recorded and reviewed in line with the MCA and best interests decision (BID) making. Whilst the registered manager provided some MCA assessments and BID making records following our assessment, these did not cover all specific decisions or include all relevant people.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The registered manager told us no one living at Ivy House Residential Care Home required a DoLS authorisation. However, we found aspects of people’s care would need to be considered as to whether they did need a DoLS authorisation. These had not been considered or assessed. People’s rights under the MCA framework had not always been upheld.

The provider had not arranged for staff to receive any recent training on the MCA and DoLS, or safeguarding training. Whilst staff we spoke with understood the signs of potential abuse and their duty to report this, the lack of recent training meant there was a risk staff were not up to date with the latest processes to ensure people’s safety and protect their rights.

However, people living at Ivy House Residential Care Home all told us they felt safe. One person said, “Yes, I do feel safe here and my family know I am as well. My [relative] has power of attorney and comes in regularly.”

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff had not always discussed risks and how to manage them with people directly when they had the capacity to understand and make their own choices about them. Instead, staff had recorded conversations with relatives without any records showing they had also directly spoken with the person. This meant people had not always been involved in managing risks.

Care plans for people who had risks associated with swallowing were not clear on what the latest professional advice was. Where staff had made decisions to update care plans and remove the requirement for a choking risk assessment, or a regular checklist to monitor their risk, we were not provided with any evidence to show this had been based on the recommendation of a qualified professional. This placed people at risk of receiving unsafe or inconsistent care.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider was unable to provide evidence they had managed and controlled the risks from Legionnaires’ Disease to the required standards. Legionnaires’ Disease is a form of pneumonia caused by legionella bacteria which can exist in water systems. Care homes are expected to have systems in place to reduce and control this risk as people living in care homes are vulnerable to this disease. The provider sent us details of the training they would put in place to address this following our assessment.

Whilst the registered manager told us they did daily walk rounds to check on the safety of the premises, these were not recorded. As such, there were no records to provide assurances that safety features in the environment, such as window restrictors were operating safely. During our assessment, we found food items had been stored on the floor in the kitchen when they should be stored above the floor. This meant the provider was not identifying risks in the environment and taking actions to ensure they were reduced.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

The provider had identified the training courses staff were required to complete. These had not identified training in all the relevant areas of care that staff were currently supporting people with. For example, dysphagia. The training matrix showed a large amount of staff training had expired or had not yet been completed. This meant no staff had in date moving and handling training, fire safety, infection control or falls prevention training. Other training courses identified by the provider showed very poor levels of completion or that the completed training had now expired. For example, person-centred care, first aid, deprivation of liberty safeguards, safeguarding, food safety and falls. Shortly after our assessment, the registered manager confirmed staff had been booked onto fire safety training and client handling (moving and handling) and these would be completed by the end of July 2026. They confirmed staff had been instructed to complete their on-line training to cover the other areas relevant to people’s needs.

The provider had failed to conduct staff recruitment processes in line with their own recruitment policy and to satisfy the requirements relating to employing staff to work in care. The provider had not always obtained their own Disclosure and Barring Service (DBS) checks when they employed staff, instead they had relied on copies of DBS checks from previous employers. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions

The provider had not obtained written references of staff conduct in previous employment to help inform their decision as to whether staff were suitable to work at the service. Nor had they documented any decisions relating to the suitability or risk assessments that were to be put in place when checks highlighted potential risks of employing staff. Records did not show that the provider had obtained a full employment history of staff to allow them to check for any gaps in employment history and the reason why.

However, people mostly felt there were enough staff to ensure people received help when they needed it. For example, one relative told us, “There’s always lots of staff about. I see staff being very busy, very caring and supportive.” Whilst another relative said, “I’d say that if there are 10 staff at the home that 8 of them are always familiar to us. When we visit on a Saturday morning generally we’ll all be in the lounge. There's always plenty of staff around and they are always quick to respond.” However, one person told us, “Sometimes, I must admit I have to wait for help.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

People were happy with the cleanliness of their home. One relative told us, “We always notice the cleanliness. There’s never a smell and [Person’s name] is always clean and well presented.” A visiting professional said, “[Person’s] room is always clean and smells nice.”

However, whilst we found the home environment to be clean, the provider had not completed any audits and checks on the effectiveness of infection prevention and control measures in place at the home. This meant there was the risk that any shortfalls in infection prevention and control systems would not always be proactively identified and improved.

We reviewed a recent risk assessment for a specific infection risk. The provider’s infection control policy included that when additional precautions to standard infection control practices were in place, the provider could seek further advice from the local infection prevention and control team. However, the risk assessment had not included any liaison with the local infection prevention control team to check that the additional transmission-based precautions being used at the time were in line with recommended good practice. Liaising with the local infection prevention and control team when managing specific risks helps the service ensure it is following good practice.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines administration record (MAR) charts had not always been fully completed and had gaps where people’s medicines should have been recorded as being administered, or refused. As such, the provider was unable to demonstrate people always received their medicines as prescribed.

Processes to help reduce the risks associated with medicines were not always consistently followed. For example, when staff had handwritten instructions on the medicines administration record (MAR) chart, these had not always been signed by another staff member to confirm they had checked it was accurate. This meant the risks from transcribing errors in people’s medicines were not always reduced.

Some people were prescribed medicines to have ‘as and when required.’ However, for one person, we found there was not sufficient detail to describe when staff should give these. The record stated just to give when the person was anxious with no direction of what to try to relieve the person’s symptoms without the use of medicine. This meant the person was at risk of receiving their medicines inconsistently.

We observed when staff administered people’s medicines they stayed with people while they took their medicines and prompted people’s involvement and independence in doing so.