Ivy Care (Reading & Newbury)

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 good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 59 (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, however, staff did not always report safety events or concerns.

Where people had raised concerns with staff we heard, “They [staff] listened to us and compromised, it’s all sorted now” and “I have made a complaint once and they sorted it.”

Referrals had been made to professionals following incidents, however there was limited documentation about action taken to keep people safe, and care plans had not always been updated following professional involvement.

There were some examples of lessons learnt to identify and embed good practice. Professionals provided positive feedback. We heard, “I feel the service is meeting people’s needs, they are very good at maintaining good communication with ASC and proactive at raising any concerns they may have.”

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 told us, “They [staff] have called an ambulance for me and have stayed with me until it arrives”, and “Whenever I talk to the provider they respond quickly. They phoned the GP surgery.”

Relatives told us they received advice from the provider, and staff were vigilant when it came to ensuring the health of their loved ones. We heard of some examples where staff were able to spot the changes and contacted the relevant healthcare professionals. However, care planning did not always contain information which accurately reflected people’s needs.

The provider did not always work well with people to understand what being safe meant to them and how to achieve that.They did not always concentrate on improving people’s lives or protecting their right to live in safety.

People and their relatives felt safe. We heard, “Yes. My [person] is very safe” and “I feel safe with them [staff].”

Safeguarding concerns were raised, staff knew where policies and details were kept, however we could not always see the correct action documented within incident forms to safeguard people.

Systems and process were not sufficiently robust to help identify potential safeguarding concerns, this was because there was a lack of written guidance for staff.

We identified incidents where concerns had not been escalated appropriately by staff, and this put people at risk. Where unexplained bruising had been documented, there was not always evidence of investigating the bruising or the action documented.

Records were inconsistent around people’s capacity and ability to consent to care and treatments. There was no evidence of how Mental Capacity assessments were carried out, or best interests’ decisions in place for people who required them. There was a lack of a robust understanding of the Mental Capacity Act 2005. The registered manager told us they would take immediate action to address this.

The provider did not always work well with people to understand and manage risks.

People felt involved in their care, we heard, “Yes, I’m involved with care discussions. We have a monthly meeting to see how things are going,” and “They listen and involve me. They check in with me and discuss my needs regularly.” However, we could not always see where care plans had been updated following these discussions.

Although people we spoke with felt involved in their care planning, we found people's care plans were not always up to date. Assessments were not always robust, key risk areas had not been fully assessed, and did not always consider risks relating to people’s safety.

Risk management plans in place were not always detailed enough to ensure staff had all the necessary information to provide safe care and treatment. For example, there was missing, or unclear information about people's physical ability and support required, medical conditions and how this affected people. There was limited guidance around what support was needed with eating, skin integrity, diabetes, and stoma care.

For people with a learning disability, there was no information about how their disability affected the person and what support they might require around communication and times of distress.

Staff felt they had enough time to provide care, and changes to people’s needs were acknowledged and dealt with in a timely manner. However, there was limited guidance within people’s documentation to enable staff to carry out care which met people’s needs.

Governance process did not identify missing and or conflicting information within people’s care plans and risk assessments.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People and their relatives told us, “My home is left clean and tidy. Doors are locked etc” and “Every time they [staff] leave, they close doors and use the key safe. Always leave my [person’s] home clean and tidy.”

The provider completed environmental risk assessments of people’s homes to ensure support was provided safely and staff were aware of the risks.

The provider did not always make sure there were enough qualified, skilled, and experienced staff.

We received mostly positive feedback about staff from people and their relatives. We heard “My [person] likes the carers. They let me know if they’re running late,” “[Staff are] very caring. It’s the way they’re trained. Never miserable.” However, we also heard, “I get tired of having to reinstate my routine. I like a core of routine staff” and “New staff don’t always know the codes.”

Staff told us they received enough training and felt the management team offered support and were quick to respond to questions. Daily notes evidenced staff were not always clear on their responsibilities to report and monitor concerns which could put people at risk. Staff documented concerns around people’s skin integrity and their mood, however there was limited evidence about what action was taken to follow up on these concerns or provide reassurance.

Staff received an induction, however there was limited oversight of further training in place. The provider ensured staff had access to further training and contacted Occupational Therapists to provider further demonstrations.

The provider assessed and managed the risk of infection, however, we could not always see where action had been taken to ensure staff understood how to use PPE appropriately.

People and their relatives told us their homes were always left clean and tidy.

Spot checks were carried out regularly. One spot check we reviewed evidenced staff not changing their gloves between personal care and preparing a meal. This was addressed during the spot check, although there was no documented action around training, following the inspection we received evidence that the service had taken action, and the staff had been retrained.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences.

People and their relatives provided positive feedback about medicines, “Staff administer medication safely,” and “Staff give the medication. We know that they get their medication in accordance with standards and records.”

Systems in place had not identified staff administered covert medicines for one person, without a MAR [Medication Administration Record] chart or supporting documentation in place, and creams were being administered with no MAR charts or guidance in place. During the inspection, the provider changed their system, introducing MAR charts for creams and body maps to identify where creams were to be applied.

Daily notes did not record why PRN [when required] pain relief was required. One person did not have medicines available, this was followed up by the office, however staff were incorrectly signing the tasks to state medication had been given despite it not being available. This was brought up with staff during a staff meeting.