Ivy Court

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 requires improvement. At this assessment the rating has remained requires improvement. This meant people were not always safe and protected from avoidable harm.

The service was in breach of legal regulation in relation to the management of medications and involving people to manage risk.

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 service did not always have a proactive and positive culture of safety. However, they did listen to concerns about safety and did investigate and report safety events. Lessons were learnt to continually identify and embed good practice. Audits of medication administration record (MAR) charts were not effective and areas for improvement had not been identified in recent audits and reviews.

The service 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. Hospital packs and MAR charts were printed off and sent with people if they needed to move between services, for example attending hospital.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. Safeguarding policies and procedures were in place and all staff had attended training so they knew how to report any concerns about people’s safety. Incidents were recorded and reviewed appropriately and there was clear communication with the local safeguarding adults team.

The service did not work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Records of care and support were completed inconsistently and, in some care plans, key information, for example sling loop configurations, was missing. People's needs were assessed and care was delivered in line with people's needs, however, care plans did not always reflect current updates. Staff knew people well and this mitigated the risks. This was a breach of regulation 12 safe care and treatment and we asked the provider to take action.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Safety checks of the premises and care environment were completed. Records were well organised and maintained.

The service made sure there were qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. People told us staff were kind and caring but at times people felt there were not enough staff available to meet their needs. One person told us, “The staff are lovely but there aren't enough. When I need the toilet there has to be two staff. It can be a long wait for the second staff member to come sometimes." Staff were recruited safely and were supported to attend a range of training courses to support their professional development.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Infection prevention and control measures were effective and personal protective equipment was available and used by staff. Outbreaks of transmissible illnesses were well managed and people were supported to remain as healthy as possible.

The service did not make sure administration and storage of medicines and treatments was safe and met people’s needs, capacities and preferences. Management of medicines was not managed safely. Audits and review of controlled drugs were not effective and had not picked up inconsistencies in recording medication administration. Stock counts of medications were not accurate and this issue had not been identified in audits and checks by staff trained to administer medications. Body maps had not clearly identified where people’s pain patches had been placed. People were at risk of harm because of poor medication administration records and processes. This was a breach of regulation 12 safe care and treatment and we asked the provider to take action.