CQC report explained · a nursing home
What the CQC found at Ivy Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2023
Rated Inadequate and in special measures; inspectors found unsafe care planning and weak management, although medicines and staffing were generally handled safely.
This was an unannounced focused inspection on 7 March 2023. Two inspectors reviewed care records, recruitment files and quality records. They also spoke with staff, 10 relatives and outside professionals.
The home was rated Inadequate overall. Safe and Well-led were rated Inadequate. Responsive remained Requires Improvement. The inspection found unclear or conflicting care plans, including information about choking, nutrition, diabetes, pressure ulcers and distressed behaviour. This created a risk that people could receive unsafe or unsuitable care, especially when agency staff were working.
Inspectors found that medicines were managed safely, the home was clean and infection control arrangements were suitable. There were enough staff to meet people's immediate needs, but the home relied on agency staff and had a high staff turnover.
The home had not fixed problems found at the previous inspection. Its overall rating changed from Requires Improvement to Inadequate and it remains in special measures.
Staff availability
Inspectors observed enough staff to respond to people's requests without long waits. A previous recommendation about staff deployment had been met.
“There were sufficient numbers of staff to support people when they needed it.” from the report
Activities and relationships
People were offered activities, including reminiscence and music. Relatives could take part in events and use a private dining room with their relative.
“During the day we saw people engaged in reminiscence activities and musical activities.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements to prevent and manage infections, including COVID-19 outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Unclear risk plans
seriousSeveral care plans contained old, conflicting or missing information. This included instructions about food and drink thickness, choking, weight loss, diabetes and pressure ulcers.
“Risks to people were not always identified, managed or mitigated in eight of the care plans we reviewed.” from the report
Agency staff and inconsistent information
seriousThe home regularly used agency staff because of recruitment difficulties. Inspectors said inaccurate care plans could leave these staff without the information needed to provide safe care.
“These agency staff would be reliant on people's care records to know what care they required and poor care planning meant that people were placed at risk of receiving inappropriate or unsafe care.” from the report
Support for distressed behaviour
seriousPlans did not always explain how to prevent, reduce or calm distressed behaviour. Some plans used language that was not respectful.
“Where people's behaviour presented a risk to others, there were not always clear plans in place on how people could be supported to reduce distress behaviours.” from the report
Weak management checks
seriousThe home's quality checks had not found the serious problems identified by inspectors. Managers also had limited oversight of the quality of new care plans.
“The significant concerns we have identified through the course of this inspection had not been identified and acted upon by the management team through the quality assurance system.” from the report
Openness and complaints
seriousInspectors found that a care plan had been edited after it was requested and that complaints were not initially disclosed. Information requests were also delayed.
“This meant we were not assured the service was being open and transparent with us at all times.” from the report
- 01What has been done to correct the old or conflicting care plans, and how is each plan now checked for accuracy?
- 02How will staff manage choking, weight loss, diabetes and pressure-ulcer risks for my relative?
- 03What information will agency staff receive before caring for my relative, and how are they being supervised?
- 04What changes have been made to plans for people who show distressed behaviour?
- 05How are complaints and feedback now recorded, investigated and included in the home's improvement plan?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 1 July 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2020
Ivy Court is rated Requires Improvement overall, with Well-led rated Inadequate, and remains in special measures because inspectors found serious management and care-record weaknesses.
Inspectors visited without notice over two days in February 2020. They spoke with people, relatives, staff and a health professional. They observed care and medicines being given, and checked care records, medicines records, staff files and management systems.
There had been improvements since the previous inspection, when the home was rated Inadequate. Medicines, safeguarding, staff training, consent processes, infection control and accident reviews had improved. People generally described staff as kind, and the environment was clean and well maintained.
However, risks and care records were not always managed safely or kept accurate. Some people had to wait for two staff to help them, care was not always personalised, and staff did not always have enough time to talk with people. The home had been without a registered manager since May 2019, with several temporary managers.
The overall rating means the home was not consistently meeting people's needs. Well-led being Inadequate means there were widespread and significant weaknesses in leadership and oversight. The home remains in special measures and CQC said it would monitor progress and re-inspect.
Improved medicines safety
Most medicines were given as prescribed, and staff followed safe procedures when administering them. Medicines checks and investigations of errors were in place.
“Records showed people received their medicines as prescribed.” from the report
Kind and capable staff
People generally described staff as kind and capable. New care staff completed introductory training and practical competence checks before working independently.
“People told us staff were usually well trained and capable.” from the report
Activities and visitors
The home offered a regular programme of group activities, trips and personal care sessions. Visitors were welcomed and encouraged to join events and meals.
“There was a regular activities schedule coordinated by a team of activities staff.” from the report
Clean, accessible environment
The building was modern, spacious and accessible. Inspectors found it clean, well presented and supported by regular safety checks.
“The environment appeared clean and well presented with no lingering malodours.” from the report
Improved complaints handling
The current manager recorded and responded to complaints more consistently. People and relatives said they knew how to complain and felt responses had recently improved.
“Most reported they felt responses had improved recently, they would be listened to and action taken.” from the report
Care records and risk information
seriousSome risk assessments and care plans were out of date, duplicated or contradictory. This could make it harder for staff to follow the right guidance safely.
“Care records were often excessive, contradictory and/or duplicated information.” from the report
Delays in care
needs fixingPeople who needed two staff often had to wait. Inspectors said staff were not deployed appropriately to meet people's needs promptly.
“Several staff, people and relatives told us that it was common to have to wait unacceptable lengths of time for two staff to be available.” from the report
Care was not always personalised
seriousCare plans did not always reflect people's wishes, preferences or routines. Examples included personal care times, soft-diet choices and activities based on personal interests.
“People were not always getting their needs met in the way they preferred.” from the report
Unstable management
seriousThe home had no registered manager and had several temporary managers. This contributed to missed improvement deadlines and inconsistent oversight.
“The provider had failed to establish consistent management or follow the governance systems in place.” from the report
Limited time and attention
needs fixingStaff were often focused on tasks and paperwork. People could be left for long periods with little stimulation or conversation.
“During the inspection people were often left unattended for long periods of time in the communal areas with little stimulation.” from the report
- 01Who is currently responsible for managing the home, and when will a permanent registered manager be in post?
- 02How are staff deployed now to prevent people who need two staff from having to wait?
- 03How have care plans and risk assessments been checked to remove contradictions and reflect each person's preferences?
- 04How are daily food and fluid records completed promptly and checked for accuracy?
- 05What evidence can you show of progress since this inspection and of the actions required while the home is in special measures?
This was a planned, unannounced inspection covering all five key questions and included observations of care and medicines, discussions with people, relatives and staff, and checks of care, staff and management records. This explanation was written from the published report of 2 April 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Ivy Court
7 rated inspections over 7 years: the service has slipped, from Good to Inadequate.
- July 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2020Requires improvementup from InadequateSafe: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2019Requires improvementdown from GoodSafe: InadequateWell-led: Requires improvement
- March 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015
Registered with the Care Quality Commission on 1 July 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.