Ivybank House Care Home

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• 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

We reviewed 2 quality statements for this key question in governance, management and sustainability and partnerships and community. We found staff understood their roles and responsibilities. The service had been going through a period of change and we saw an improvement in the governance oversight from the new provider. There were regular audits being completed to maintain the level of oversight needed. The service was in the process of recruiting a new management team to oversee the service. People had access to professionals as and when needed. There were regular activities taking place in the home and regular feedback was being sought by the provider from people, relatives and professionals. However, the provider had started using a new electronic care planning system 8 weeks prior to the assessment and work was needed to ensure care plans and risk assessment were up to date and accurate. Extra resources had been brought in and the provider had an action plan in place to address this.

This service scored 21 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff understood their roles and responsibilities. They were aware of how to record information and to keep people’s data safe. Some staff told us the change of systems and provider had impacted governance in areas such as care plans and risk assessments. Leaders told us they were assured the audits being completed maintained the level of oversight required. The Registered Manager had resigned from their role, a new Manager had been recruited and was due to commence in November 2024. The service was also in the process of recruiting a Deputy Manager. Leaders told us about their plans for the service and the priorities for the new management team when they commenced in their role.

There was a policy and procedure in place for the availability, integrity and confidentiality of data, records and data management systems. There was a programme of regular quality reviews, mock inspections and audits being completed by the provider with an action plan in place to address shortfalls needing improvement. The service was going through a period of change and we saw an improvement in the governance oversight from the new provider. However, we found care plans and risk assessments did not have enough information to keep people safe, for example, missing or conflicting information. Some care plans did not have person-centred information available to help new or agency staff understand people’s wishes and needs. For example, some areas such as religion, pronouns, meal and drink preferences were not filled out for some people. One care plan also did not show an understanding of a person’s dementia’s diagnosis or communication needs. Leaders had identified areas for improvement within the service including the concerns found relating to the accuracy of care plans and risk assessments and were working to rectify this with an established action plan with clear timescales for completion.

People told us they had regular visitors to the home. People told us they enjoyed the minibus trips out of the home and raised concerns that these would be stopped due to an activities staff member leaving. The leaders reassured us bus trips out of the service would continue by utilising other staff who were eligible to drive the minibus. People told us they had professionals visiting the service to meet their needs.

Staff told us relatives and professionals regularly visit the service. Leaders told us they had engaged with people about the type of activities they wanted in the service. They have been working on one-to-one activities for people who did not want to participate in group activities.

Professionals told us the new electronic care planning and risk assessment system was positive for the service and allowed professionals to access care records in a timely manner. Professionals were assured the service would contact them if people needed additional support. They commented about the range of activities in the service compared to other services they visit. The local authority told us the provider regularly communicated about the changes in the service, and they were up to date about the plans for the future.

There was evidence the provider had liaised with various health professionals to meet people’s needs, and working in partnership with them. The provider had gained regular feedback from people and professionals which was mainly positive. We raised concerns with the provider about people’s access to dental services and were assured by the plans in place. The service had recently changed their service user bands and had provided internal training and engaged with the local authority to provide specific training for staff in dementia. This training was completed in March and July 2024 with other dates due to be scheduled in for new recruits.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.