CQC report explained · a residential care home
What the CQC found at Ivy Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found systems to protect people from abuse, assess risks and learn from incidents. Medicines, infection control, staffing and recruitment were also found to be managed safely.
- Effective?
- Good
- Care plans reflected people's needs and aspirations. Staff had relevant training, regular supervision and competency checks, and people were supported with food, healthcare and decisions about their care.
- Caring?
- Good
- This question was not inspected during this visit, so the report gives no new rating or detailed findings for it.
- Responsive?
- Good
- This question was not inspected during this visit, so the report gives no new rating or detailed findings for it.
- Well-led?
- Good
- Inspectors found effective governance, clear management responsibilities and a culture focused on people's needs and wishes. People, relatives and professionals were involved in improving the service.
What inspectors found, February 2023
Ivy Lodge was rated Good; inspectors found safe, person-centred care and effective management, with agency staff used to cover staffing shortfalls.
This was an unannounced inspection. Inspectors visited on 12 January 2023 and completed inspection activity between 12 and 18 January. They spoke with people, staff, relatives and professionals, and reviewed care, medicines, recruitment and management records.
The home was rated Good overall. Safe, Effective and Well-led were all rated Good. Inspectors found people were protected from abuse, medicines were managed safely, care plans reflected people's needs, and managers had effective checks on the quality of care.
The inspection was prompted partly by concerns about a closed culture, staff training and management. Inspectors found no evidence that people were at risk of harm from these concerns. The report says the last rating was Good, published in October 2017.
Personalised care
Care plans reflected people's individual needs, aspirations and health needs. People and those important to them were involved in reviewing support.
“People had care and support plans that were personalised and reflected their needs and aspirations, including physical and mental health needs.” from the report
Safe medicines support
Medicines were managed safely, with staff training and checks of their competence. The home also followed principles intended to avoid excessive use of medicines.
“Staff were trained in the safe management of medicines. Competency checks were carried out to make sure they were following the correct procedures.” from the report
People's involvement
People had a say in their meals, rooms, care and the recruitment of staff. They also took part in regular house meetings.
“People were involved in staff training and interviews to recruit staff.” from the report
Effective management
The report found that governance systems helped managers monitor quality, protect rights and keep people safe.
“Governance processes were effective and helped to hold staff to account, keep people safe, protect people's rights and provide good quality care and support” from the report
Use of agency staff
minorThe home used regular agency staff to cover staffing shortfalls. Inspectors said efforts were made to use the same agency staff so they could become familiar with people's needs.
“Regular agency staff were in place to manage shortfalls in staffing numbers.” from the report
- 01How often are agency staff used to cover staffing shortfalls, and how are they introduced to each person's needs?
- 02How do you check that staff remain competent to administer medicines safely?
- 03How are people involved in reviewing their care plans and setting goals?
- 04How are restrictive interventions recorded, reviewed and reduced where possible?
- 05How do people and relatives give feedback, and what changes have been made as a result?
This inspection covered Safe, Effective and Well-led; Caring and Responsive were not inspected, and ratings for questions not inspected were carried over from the previous inspection. This explanation was written from the published report of 1 February 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, December 2017
Ivy Lodge was rated Good; inspectors found safe, caring and personalised support, with some medicines records needing improvement.
The inspection was unannounced and took place on 12 October 2017. Inspectors spoke with people living at the home, relatives, staff and a healthcare professional. They observed care, looked around the building and checked care plans, recruitment records and management documents.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe. Inspectors found enough staff, suitable risk assessments, safe recruitment and support that promoted choice, independence and dignity.
The home supported people with health appointments, food, activities and daily living skills. Care plans were personalised and the home had strong links with the local community. Some medicines records and procedures were not fully complete, but the registered manager acted on issues found during the inspection.
At the previous inspection in March 2016, the provider was not meeting regulations about good governance and staff support. Inspectors found that a number of improvements had been made by this inspection.
People felt safe
People and relatives said they felt safe. Inspectors found enough staff and risk assessments covering areas such as behaviour, money, alcohol and medicines.
“People told us they felt safe and this was supported by information from relatives.” from the report
Personalised support
Care plans recorded people's likes, dislikes, preferred names and support needs. People were involved in their care and encouraged to make choices.
“Care plans contained person centred information including a person's likes and dislikes.” from the report
Activities and community links
The home offered activities such as gardening, swimming, walking, bingo and community events. People were encouraged to take part in local activities and charity work.
“There were well established links with the community such as, a gardening plot in the community allotment and people took part in a variety of charity fund raising events.” from the report
Medicine procedures were out of date
needs fixingThe medicines policy needed updating. One care plan did not show that a capacity test for self-administering medicines had been completed.
“We inspected the registered provider's Medications Management Policy and Procedure document and found this was out of date and required to be reviewed.” from the report
Controlled drug records
needs fixingControlled drugs were stored safely, but there was initially no separate register recording their receipt and administration. The manager ordered one during the inspection.
“Controlled drugs (CD's) were stored in a separate medicine cabinet. We saw CDs were recorded on the MAR charts but there was not a separate register to record the receipt and administration of CD's.” from the report
A cream body map was incomplete
minorOne medicine record said a cream should be applied to affected areas, but the body map showing where to apply it had not been completed. Staff said they would correct this straightaway.
“We saw one MAR stated a cream needed to be applied to the affected areas as directed but the body map to indicate where the cream should be applied had not been completed.” from the report
- 01How do you assess and record whether each person has the capacity to self-administer medicines?
- 02Has the separate controlled drugs register been put in place, and how is it checked?
- 03How do you make sure medicine records, including body maps for creams, are complete?
- 04What changes were made after the March 2016 inspection, and how do your audits show that these improvements have continued?
- 05How will you support my relative to take part in activities, maintain life skills and stay involved in the community?
This was an unannounced inspection on 12 October 2017 that assessed the home across all five CQC questions, following up improvements identified after the March 2016 inspection. This explanation was written from the published report of 8 December 2017 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 Lodge
3 rated inspections over 7 years: the service has held its Good rating throughout.
- February 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2017Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- June 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 January 2011.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 99 live-in carers within about an hour of Barnsley
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 £980 to £1,260 a week. 82 can care for a couple. 12 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“Ivy was very kind and gentle in all her dealings with my late mother. They got on very well and were able to share a joke and a laugh.”
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.