Ivy Court

Updated 1 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors. An Expert by Experience made telephone calls to people and their relatives to ask about their experience of the service. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Ivy Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with 10 relatives of people who used the service. We spoke with 12 staff members including the registered manager, unit leads and care staff. We reviewed the care records for 10 people and 3 recruitment files. Multiple records relating to the quality, safety and monitoring of the service were reviewed.

Updated 1 July 2023

About the service

Ivy Court is a care home which at the time of inspection was providing personal and nursing care to 44 older people, some of whom were living with dementia. The service can support up to 71 people.

People’s experience of using this service and what we found

Risks to people were not adequately planned for, managed or mitigated. Six of the care plans we reviewed contained old or conflicting information, making it difficult to ascertain what care people required to keep them safe. The service was currently using a number of agency staff due to difficulties in recruitment. These staff would be reliant on these inaccurate care plans to know how to care for people, placing them at risk of receiving inappropriate and unsafe care.

Care plans failed to provide robust and consistent information on how to support people who displayed distressed behaviours. In the case of three people who had distressed behaviours, there was not always sufficient information in care planning with regard to how people could be positively supported to avoid, reduce or deescalate the situation. Some people with complex mental health conditions which could impact their well being did not have care plans for these.

The service did not demonstrate how they met their responsibility to be open, honest and transparent. Examples included one document we requested had been edited prior to it being sent to us to include necessary information which was not there before our request. Complaints that had been made by one family member were not included in the complaints file and were not mentioned when we asked about complaints that had been made.

The quality assurance system did not appropriately identify the issues we found at inspection. Therefore, this was ineffective.

The service has had five inspections since May 2017 and has only been rated good at one of these inspections. This ‘good’ rating and compliance with regulations was only sustained between January and October 2018. This means that people have received an inconsistent standard of care which often did not meet regulations or fundamental standards and the provider has failed in their responsibility to address these issues and protect people from harm.

Medicines were managed, monitored and administered safely.

The service was clean and there were appropriate procedures in place to minimise the risk of the transmission of COVID-19.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was ‘requires improvement’ (2 April 2020).

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 17 and 18 February 2020. Breaches of regulations 9: Person Centred Care, Regulation 12: Safe Care and Treatment, and Regulation 17: Good Governance. At this inspection the service remains in breach of these regulations.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-Led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ivy Court on our website at www.cqc.org.uk

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and recommendation

We have identified breaches in relation to how the service identifies, monitors and manages risks to people, care planning around distressed behaviours and the governance of the service.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

We have made a recommendation around how the service ensures it can demonstrate it has acted upon feedback from people and their relatives.

Follow up

The overall rating for this service is ‘Inadequate’ and the service therefore remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.