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Inspection Summary

Overall summary & rating

Requires improvement

Updated 21 June 2019

About the service:

The service had not originally been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. This guidance was implemented in 2017 after the service had registered with us. This was because there was The House that accommodated nine people, including one flat and an annexe, and there were also four bungalows, Tyneham, Crantock, Kenley and Trafalgar, that could each accommodate four people.

The service is registered for 25 people and there were 23 people living at Ivers during the inspection. The service had previously been a college but no longer operated as such. It would be unlikely that we would register this model of services now when considering applications for services for people with a learning disability and/or autism.

The provider and manager had recently changed the way the service operated so that The House and two of the bungalows in a group were managed by separate deputy managers and staff teams. This was with the aim to personalise the services and to better reflect the Registering the Right Support Guidance.

People’s experience of using this service:

The manager and staff did not always have a good understanding of the Mental Capacity Act

(2005) (MCA) or Deprivation of Liberty Safeguards (DoLS). This was because the conditions on people's DoLS were not known or understood by the managers or staff. People’s representative and or professionals had not always been consulted or involved in making best interests decisions.

The provider and manager’s oversight and monitoring of the service had not effectively identified all the shortfalls for people. There was an action plan in place to address the shortfalls identified by the provider’s monitoring but not the areas identified during the inspection.

People were safe from the risk of abuse. Risks were assessed but the risk management plans needed to be reviewed alongside people’s assessments and care and support plans. These reviews were in progress. However, people’s monitoring records were not accurately or fully completed.

There were enough staff on duty, but this included a high number of agency staff. Recruitment and retention remained difficult.

Staff felt well supported but had not received supervision and development sessions. Not all staff had completed the provider’s training and induction programme and staff had not been trained in people’s communication methods. There was a plan in place to address this.

Overall, staff were kind and caring and respected people’s individuality and diverse needs. However, improvements were needed in relation to people’s dignity and privacy and staff respecting people’s identity.

Care and support was personalised to meet people's care, social and wellbeing needs. People had access to a range of activities that met their interests.

People and staff spoke highly of the manager and said they were listened to.

Rating at last inspection: Good (report published 25 May 2017).

Why we inspected: The inspection brought forward due to information of concern.

For action we have told the provider to take please refer to the end of full report.

Follow up: We will continue to monitor the intelligence we receive about this home and plan to inspect in line with our re-inspection schedule for those services rated Requires Improvement.

For more details, please see the full report which is on the CQC website at

Inspection areas


Requires improvement

Updated 21 June 2019

The service was not always safe.

Details are in our Safe findings below.


Requires improvement

Updated 21 June 2019

The service was not always effective.

Details are in our Effective findings below.


Requires improvement

Updated 21 June 2019

The service was not always caring.

Details are in our Caring findings below.


Requires improvement

Updated 21 June 2019

The service was not always responsive.

Details are in our Responsive findings below.


Requires improvement

Updated 21 June 2019

The service was not always well-led.

Details are in our Well-Led findings below.