Ivy Court

On this page

• 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant there were some shortfalls in service leadership and governance processes.

The service was in breach of legal regulation in relation to the governance of the service.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Appropriate policies and procedures were in place. People told us they were happy with the management team. One person said, "I think [the registered manager] is doing a good job."

Leaders embodied the culture and values of their workforce and organisation. They had the skills, knowledge, experience and credibility to lead effectively but oversight of quality assurances processes, specifically management of medications and responding to concerns was limited. A family member told us, “I think a more hands on approach would be better. I did raise my concerns about being under-staffed and the time [family member] is kept waiting for a second member of staff but [the registered manager] said that they are fully staffed. That doesn't help [family member] when she they [are incontinent]."

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had appropriate policies and procedures in place that supported staff to speak up and their anonymity would be protected.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. A member of staff told us they felt supported by the management team and colleagues were approachable, “When I first started working here, I wasn't sure how to respond to people when they were asking why they were living at the home. Colleagues supported me and now I know people really well and enjoy my role.”

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes. Audit processes and reviews of medications administration processes and management of controlled drugs were not effective. Errors in stock counts and recording of administration of controlled drugs were identified by the inspector but had not been identified on a recent medications audit by the team. This meant that the management team did not have oversight of risk. People were at risk of harm because of poor governance and oversight processes of medication administration. This was a breach of regulation 17 good governance and we asked the provider to take action.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. There was evidence of partnership working with local services and information was shared appropriately with GP practice to ensure continuity of care and support. A health professional told us, "Staff are good here and they understand and know people well. It's a lovely place and there is always a nice atmosphere."

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. Accidents and incidents were reviewed and lessons were learnt to continually identify and embed good practice. There were, however, inconsistencies in how some audits and reviews were completed and how areas for improvement were identified. For example, audits of medications processes were not effective and feedback from people and families about deployment of staff had identified areas for continued improvement.