Ivy Court

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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The provider was previously in breach of legal regulations in relation to safe care and treatment. Improvements were found at this assessment, and the provider was no longer in breach of regulation 12.

This service scored 75 (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.

Processes were followed to ensure all accidents, incidents, safeguarding concerns, and complaints were appropriately investigated and actioned. Professionals fed back that people were safe. One professional said, “Risks are well‑managed through up‑to‑date, person‑centred assessments.”

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.

Information was shared with agencies to ensure continuity of care. We found staff and leaders made appropriate referrals to external professionals and staff followed their guidance. Assessments of people’s needs prior to moving in were carried out and the service sought support from the GP practice, and care home support team where necessary. The service worked with the local community nursing service to ensure people who needed nursing received support in a timely way.

People were supported to understand what staying safe meant for them. The provider worked with people and healthcare partners to identify the safest ways to meet their needs while promoting their rights and independence. Staff focused on improving people’s lives while protecting their right to live free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Safeguarding concerns were shared quickly and appropriately. Clear safeguarding policies and procedures were in place, and all staff had completed training, so they knew how to recognise, and report concerns about people’s safety. Incidents were recorded and reviewed appropriately, and there was effective communication with the local safeguarding adults’ team. Records showed safeguarding referrals were made to the local authority and the Care Quality Commission when required. One professional said, “We often make recommendation to homes. The manager is open to these recommendations and will discuss the best way to implement them.”

Where people were subject to restrictions, appropriate legal authorisations had been sought. People can only be deprived of their liberty when it is in their best interests and lawfully authorised under the Mental Capacity Act (MCA), usually through Deprivation of Liberty Safeguards (DoLS) applications in care homes.

Processes to safeguard people were embedded and helped ensure risks were identified, acted upon and monitored effectively.

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. Staff knew people well and were aware of people's risks and how to keep them safe.

The registered manager had robustly reviewed and updated people’s support plans and risk assessments. This had been done with input from relevant healthcare professionals, family members and people themselves. This meant support plans reflected people’s needs and wishes, including how people wanted to manage risks. One professional said, “I have seen staff manage residents very well in potential conflict by using distraction techniques really well.”

Risk assessments were completed regularly. Recognised best practice tools were used to assist these assessments. There was clear and detailed information available for staff about people’s specific health needs, including risks associated with those needs, things for staff to be aware of, and actions for staff to take in different situations. The registered manager had proactively liaised with healthcare professionals to ensure guidance for staff was correct and contained accurate and appropriate information. As a result, staff had clear and consistent guidance to follow to enable them to manage risk positively. This had notably improved the quality-of-care people received.

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 provider detected and controlled potential risks in the care environment.

We observed 1 window restrictor which was broken and 2 chemical products safely stored. These are substances that are hazardous to health such as cleaning substances. The registered manager took prompt action to address these concerns during our visit.

The building was a purpose-built care home and was very well-maintained. On the day of assessment, the home was clean and free of malodours. It had been designed with wide corridors to accommodate wheelchairs and equipment. All rooms had en-suites, there were adapted bathrooms on each floor. There was level access throughout the building, including garden areas.

A range of health and safety checks were completed including fire drills, door checks, emergency lighting and water safety. The home had maintenance staff who were responsible for carrying out regular safety checks. A professional said, “The environment is clean, safe, and well maintained‑maintained.”

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.

We observed staff interacting with people and found there were sufficient numbers of staff available to meet people’s needs. Staff were deployed effectively and worked well as a team to ensure people received care in a timely way. We received feedback from some relatives which didn’t reflect what we saw on inspection. Relatives said more staff were needed at specific times like evenings or weekends, we fed this back to the registered manager who agreed to look into it.

Staff recruitment records demonstrated relevant checks were completed before staff started working at the service. This included an application form, written references, proof of identification and Disclosure and Barring Service [DBS] checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Newly employed staff received an induction and were given the opportunity to ‘shadow’ more experienced staff to ensure they understood the routines of the service and their roles and responsibilities.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was exceptionally clean, hygienic and odour free. Staff were clear about their roles and responsibilities to ensure people were protected by the prevention and control of infection arrangements at Ivy Court. Staff had access to policies and procedures on infection control and had sufficient Personal Protective Equipment [PPE]. Staff were observed using PPE appropriately and when required. Audits relating to the service’s infection, prevention and control arrangements were conducted at regular intervals and demonstrated there was a good level of compliance. Staff had received appropriate infection, prevention and control training.

The provider made sure that medicines management was safe and met people’s needs, capacities and preferences.

The medication rounds were evenly spaced out throughout the day to ensure people did not receive their medicines too close together or too late. Observation of staff practice showed staff undertook this task with dignity and respect for the people being supported. Staff who administered medication were trained and had their competency assessed to ensure they remained competent to undertake this task safely.

Medicine records were maintained to a good standard and Medication Administration Records [MARs] demonstrated people received their medicines as they should and in line with the prescriber’s instructions.

Audits were effective and helped drive ongoing improvements in the service. During our review, we found guidance for some as and when required medicines occasionally lacked enough detail to clearly record why the medicine was to be administered. However, other records were fully completed and provided clear, person-centred instructions. The team leader told us they would support staff to improve the level of detail recorded to ensure all guidance was consistently clear.