Ivy Court

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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to governance. Improvements were found at this assessment, and the provider was no longer in breach regulation 17.

This service scored 82 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The registered manager had provided staff with additional training and support to increase their knowledge and drive improvements. A health professional told us, “Communication is brilliant, management and team leaders keep thing well organised, have meetings with residents and relatives to see what they want.” We observed the registered manager’s open-door policy with staff, people and their relatives freely entering the office. A relative said, “I get updated and pop in and see the manager when I am there. I have seen the care plan, and I've also had 2 discussions with the DoLS team where we discussed [person’s] care. I am kept up to date.” Staff meeting minutes demonstrated inclusivity and gave staff a voice. Feedback surveys were conducted so staff, people and their relatives, had an active voice in how the service developed.

The provider had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

All the people we spoke with were highly complementary of the leadership at the service, and how they role modelled the values of care and compassion to their team.

Throughout the assessment, the registered manager demonstrated a strong passion for person- centred care and had exceptional knowledge of the people living at the service. It was evident the service was providing quality care focusing on people achieving outcomes. One health professional said, “The home is open to continuous improvement, when recommendations are made the manager is happy to discuss and implement changes.” Another professional said, “I have found Ivy Court to be responsive and thorough.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service had appropriate policies and procedures in place that supported staff to speak up, and their anonymity would be protected.

Staff expressed positive views regarding the management team. They highlighted the effectiveness of the open-door policy, that it encouraged them to voice concerns and share suggestions, all of which were addressed in a timely manner. One staff member told us, “I get support whenever I need it. The management team are good and try their best. They are approachable and will discuss things as required.”

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.

The provider valued diversity in their workforce and worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. All staff completed training in equality and diversity.

Staff felt supported and included regardless of their background. The provider had policies and procedures in place to create an inclusive environment that upheld the principles of equality and diversity. The provider was aware of their duty as an employer, to understand and respect people’s and staff’s protected characteristics to prevent discrimination.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.in a timely way.

The service had significantly improved since the previous assessment, and the registered manager expressed their passion and drive for making improvements and embedding them into practice.

A range of quality assurance systems were in place to monitor and improve the service. These had been effective in identifying areas for development. When issues were identified, audits were strengthened and increased in frequency to enable prompt action, and improvements were implemented accordingly.

The registered manager completed walkarounds of the home, which included checks on risk, people’s care, infection control, the dining experience, colleagues and the environment, and these were recorded. Walkarounds were effective in promptly monitoring standards; however, some records did not clearly specify which bedrooms had been checked or which staff had been asked about policies. While the walkarounds were effective overall, greater consistency in the level of detail recorded would further strengthen the assurance these checks provide.

The provider carried out quality monitoring at the service to help share learning and ensure consistent high standards. They supported the registered manager and demonstrated they were committed to addressing any concerns or ideas to improve the quality of the service.

The home had policies and procedures in place which covered all aspects of the service and were reviewed and were up to date.

Staff meetings were held regularly, and all aspects of the service were discussed, for example people's care needs, maintenance and staffing issues. Staff told us how they felt they were now listened to by managers and this helped implement change for the better. Staff told us they felt appreciated by the management team and they worked well as a team.

The provider demonstrated a strong understanding of their duty to work collaboratively so that services operated seamlessly for people. They shared information and learning openly with partner organisations and worked in partnership to drive improvement.

The management team and staff had developed highly effective relationships with external professionals, and the provider had taken appropriate and well considered steps to improve outcomes for people by working closely with partner agencies.‑considered steps to improve outcomes for people by working closely with partner agencies.

The home had exceptionally positive and productive relationships with health and social care professionals. Feedback from professionals was consistently complimentary about the leadership team. One professional told us, “Leaders promote a positive culture and high standards across the home. This has significantly improved since the current registered manager has been in post.”

Other professionals described strong communication and a cohesive approach, saying, “Communication is brilliant, management and team leaders keep thing well organised, they have meetings with residents to see what they want, and the relatives and I have found the home manager to be open and transparent. I also find that the manager and the deputy work in the same way making for continuity when dealing with the home. The home is open to continuous improvement, as I have detailed above when recommendations are made the manager is happy to discuss and implement.”

People were supported to attend appointments when needed, and professionals visited the home appropriately to meet individuals’ physical or emotional health needs. Staff ensured people had timely access to the right support, and partnership working contributed to improved wellbeing and positive outcomes.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. When incidents, accidents or complaints had occurred, investigations had been carried out to understand the cause and see if anything could be done differently in the future.

The provider and management team were committed to continuous improvement of the service. The management team demonstrated their understanding of quality performance and regulatory requirements and had made good progress against the action plan formulated at the last inspection, to show what action would be taken to make improvements.