Ivy House Residential 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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 46 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Leaders told us they had not as yet developed and embedded systems and processes to regularly check on the quality and safety of services, and these were still in development. In addition, staff had not been supported to complete training relevant to their job role and to underpin a quality and safety approach to care. As such, a clear strategy and vision for Ivy House Residential Care Home based on quality and safety was not yet in place.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Leaders were not always clear on how to apply the principles of the Mental Capacity Act 2005. They had not developed and embedded audits and checks to help ensure the quality and safety of care.

The provider fostered a culture where people felt they could speak up and their voice would be heard.

Staff we spoke with told us they understood the duty to speak up if things were not done correctly or they were worried about things at the service. They told us the registered manager encouraged them 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 told us they felt treated fairly and found the registered manager approachable. Leaders understood how staff may have different needs due to religious beliefs and how these could be met. This helped to ensure staff were treated fairly.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We found systems had not been operated effectively as the last comprehensive medicines management audit had been completed in October 2024. We found errors on medicines administration record (MAR) charts that audits would have been able to identify and improve had they been operated effectively.

There was not an effective system in place to ensure staff remained up to date with their training. The training matrix provided by the registered manager showed multiple subjects of required staff training had expired or had not been completed.

Reviews of accidents and incidents were not effective as they had not identified the need to notify the Care Quality Commission (CQC) or report under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) for relevant incidents.

There was no system in place to analyse falls in the service, and whether there were any patterns in times, places or circumstances that had contributed to falls. This meant there was no effective system in place to learn lessons and improve the quality and safety of the service from falls incidents.

Records were not always accurate, complete or made contemporaneously. We found people’s medicines administration records were not always complete. Staff used a computer in the office to update people’s care records and a staff meeting had advised staff to adjust the time of records accordingly if they had made these in retrospect. This meant there was not a culture of contemporaneous record keeping in the service.

Other care records were not always completed with full details. For example, one person’s fall record provided no detail as to the circumstances of the person’s fall. This meant there was limited information to review and identify what had gone wrong and what improvements could be made to prevent a similar incident reoccurring.

Other records were not complete, for example, food serving temperatures had not been consistently recorded. Other records were inaccurate. For example, the date of a fall on the home’s accident form was different to the corresponding RIDDOR report that had been completed shortly after our assessment.

People’s care plans were sometimes incomplete as they lacked detail as to what care the staff provided. For example, details of what checks should be made on a person when they were in their bedroom, and what actions staff should take when providing personal care to a person.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Leaders had not always shared information with partner agencies. For example, they had not always notified the Care Quality Commission (CQC) or reported under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations).

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system.

Not all opportunities were taken to learn from incidents and make improvements. Leaders had not always completed reviews of accidents and incidents to identify whether there was any further investigation needed or whether they could make improvements. Leaders had not ensured staff had completed the training identified as required for their role.