Ivybank House 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 service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

Staff knew how to escalate concerns and how to record any safety incidents. Staff said they were updated following incidents and any learning from them was shared. Staff had access to relevant policies and procedures to manage safety events.

We saw leaders reviewed incidents and ensured any required actions were completed. Leaders analysed incidents monthly for any trends and actions were taken to reduce similar incidents. For example, the registered manager identified there had been an increase in falls at weekends over a 3-month period. The registered manager said they had reviewed how staff were deployed over the weekend, and this had led to a significant drop in falls occurring during this time.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People were required to have a full pre-admission assessment before they were admitted to the service and staff were made aware of people needs.

The service held daily meetings with heads of departments and senior carers to review key operational matters for the day, including updates on resident admissions and discharges.

The provider had strengthened communication with health care professionals and staff to ensure people’s needs were met appropriately. The registered manager said they now hold regular meetings with health professionals and have introduced a communication book to ensure important healthcare information is shared effectively.

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 understood their role in preventing abuse and the actions to take if they had any safeguarding concerns. Staff were trained and had access to safeguarding policies. The provider had clear processes to investigate concerns and take action to keep people safe. For example, following an incident where a person had sustained a pressure injury, staff had received training to understand about skin integrity.

Relatives we spoke with felt their relation was safe living at the service. One relative said, ‘“From my point of view [person] is being looked after and is safe. Before we came away last time, [person] told me that they felt much safer.”

Deprivation of Liberty Safeguards (DoLS) applications were made for people where appropriate, in line with legislation.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People had detailed care plans and risks assessments tailored to meet their needs. Care plans reflected people’s preferences, health conditions and support requirements. However, there was 1 occasion where a recent update to a risk assessment had not yet been reflected in the corresponding care documentation. This meant staff had conflicting information. There was no evidence the person had come to harm and the provider promptly addressed this.

There were also shortfalls in record keeping which had led to some care delivery not being recorded properly. While care had been delivered, records did not always provide a timely account of this. The provider told us they had already identified these shortfalls and were working with staff to improve this.

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 home was safe and well maintained. Regular checks were completed to help ensure the safety of the care home’s physical environment and fire safety equipment. Staff we spoke with told us they had been involved in fire evacuation practices. We reviewed records of checks carried out to ensure the premises were safe. These included electrical, water temperature, and fire safety checks. The service was undergoing refurbishment at the time of our visit. We saw appropriate risk assessments had been completed to ensure people’s safety during the works.

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.

People and relatives did not raise concerns about the staffing levels at the service. Relatives we spoke with told us staff appeared to be well trained.

Leaders told us they used a dynamic dependency tool to assess the staff levels needed at the service weekly. We reviewed this assessment which confirmed staffing levels were appropriate.

Recruitment procedures were in place to ensure staff were recruited appropriately. This included ensuring all the necessary background checks were completed including enhanced Disclosure and Barring Service (DBS) checks for working with adults. These checks provide employers with essential information such as previous convictions or cautions.

Staff told us they received regular training which was appropriate and relevant to their role. The providers training matrix confirmed this. One staff member told us, “The training I have received so far has been relevant and well structured. It covers key areas needed to deliver safe and effective care. I appreciate that ongoing training and professional development are encouraged here.” The provider told us additional training had been arranged for staff to improve their awareness of health conditions.

Records showed staff received regular supervision and staff confirmed this.

The provider had not always managed the risk of infection. They did not always detect and controlled the risk of it spreading.

We received mixed feedback from relatives about the cleanliness of the service. One relative said, “I think [the service] is a lot cleaner now.” Another relative reported issues around a smell which was a blocked sink in their relative’s room. The relative felt the service was not very responsive in getting the drain unblocked. The registered manager told us they had arranged to this to be unblocked but needed to wait for this to happen.

During our visit, we observed some moving and handling equipment appeared visibly unclean, which posed a potential infection risk. The registered manager responded promptly and took immediate action to address the issue.

We saw a programme of cleaning was in place, however there were gaps in some of the deep cleaning tasks. Additionally, staff told us they did not always get time to compete a deep clean. The registered manager told us this was due to a vacancy in the team which had now been filled.

However, an Infection control policy and procedure was in place and staff had completed required infection control training.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were administered as prescribed and stored safely, with consistent monitoring of room and fridge temperatures. Staff used an upgraded electronic Medicines Administration Record (MAR) system and had completed relevant training, with annual competency checks in place. This meant staff were trained to safely support people with their medicines.

There was effective management oversight of medicines, including quarterly audits and monthly spot checks, with high compliance levels. As required medicine (PRN) had protocols and risk assessments were up to date, and care plans were person-centred and detailed. No missed doses were found in the sample reviewed.

Medicines incidents were well-managed, with no recent high-risk errors. The home maintained good communication with GPs, including weekly rounds and annual reviews. Minor issues were identified, such as one instance of incorrect patch rotation and inconsistencies in recording non-allergy status, but these were promptly addressed by the registered manager.