7 March 2023
During an inspection looking at part of 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.