We inspected this service on 13 September 2017. Ivy Leaf is a care home which provides accommodation and support for up to 14 people who may be living with dementia. There were 12 people living there at the time of our inspection. On our last inspection on 20 August 2015 we rated this service as Good; at this inspection we found that the service remained Good.

There was a registered manager in the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People continued to receive safe care and there were enough staff to provide support to people to meet their needs. Staff had a good understanding of safeguarding people and what constituted abuse or poor practice and how to act if they suspected harm. Staff had been suitably recruited to ensure they were able to work with people who used the service. People received their prescribed medicines safely.

The care that people received continued to be effective. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People received support to stay well and had access to health care services. People liked the food that was prepared and they had a choice about what they ate and drank. Staff had training and professional development that they required to work effectively in their roles.

The care people received remained good. People had developed positive relationships with the staff who supported them respectfully and with kindness. Staff helped people to make choices about their care and their views were respected. They continued to have opportunities to be independent and were involved with carrying out domestic living skills. Staff knew people and their family well. The staff understood the importance people placed on their possessions and enabled them to look after them. People were confident that staff supported them in the way they wanted.

The care people received continued to be responsive. People’s family and friends could visit and continued to play an important role. People knew how to make complaints and were confident that the staff and provider would respond to any concern and they could approach them at any time.

The service continued to be well-led. Systems were in place to assess and monitor the quality of the service. People and staff were encouraged to raise their views about the service on how improvements could be made.

We carried out an unannounced inspection of the service on 20 August 2015.

Ivy Leaf is a care home which can provide a service for up to 14 people. There were 13 people living there at the time of our inspection. The majority of people living at the home are older people living with dementia.

Ivy leaf is required to have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of the inspection a registered manager was in post.

During our last inspection on 7 April 2014 we identified one breach of the Regulations of the Health and Social Care Act 2008. This was in relation to assessing and monitoring of the quality of service provision. The provider sent us an action plan detailing what action they would take to become compliant with this regulation. At this inspection we found the provider had made the required improvements. There were systems in place that monitored the quality and safety of the service. Additional audits and checks had been introduced and were working well.

At this inspection people who lived at Ivy Leaf and their relatives told us they were safe. There were processes and systems in place to protect people from the risk of harm. This included safe recruitment and staff training in safeguarding people against the risk of abuse.

People’s health and social care needs had been assessed and associated risk plans and plans of care developed. These were reviewed regularly and people and their relatives were included in discussions and decisions.

People told us that they received their medicines safely and we saw the administration and storage of medicines were correct. There were suitably qualified staff that were deployed appropriately to meet people’s needs. The environment was safe and met people’s individual needs.

CQC is required by law to monitor the operation of the Mental capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. This is legislation that protects people who are unable to make specific decisions about their care and treatment. It ensures best interest decisions are made correctly and a person’s liberty and freedom is not unlawfully restricted. We found people’s human right were protected because MCA and DoLS were understood by the registered manager and deputy manager and adhered to.

People told us that they were happy with the food choices and that their dietary and hydration needs were met. Where people required support with eating and drinking this was provided in a sensitive and respectful manner.

People said that they were supported to access healthcare services and that they had visits from the GP and other health professionals. We saw the provider worked with healthcare professionals and sought advice and support when required.

Staff were appropriately supported, which consisted of formal and informal meetings to discuss and review their learning and development needs. Staff additionally received an induction and ongoing training.

Some concerns were identified with how staff were deployed. The provider took immediate action and an increase in staffing levels insured people were safe and had their individual needs met.

People said that staff were kind, caring and respectful and that their dignity was maintained and individual needs met. Additionally, people gave examples of how they were supported with activities, interests and hobbies. Staff were observed to be attentive to people’s needs and supportive to people’s choices.

Confidentiality was maintained and people had access to independent advocacy information and the provider’s complaint procedure. People and their relatives or representatives were given opportunities to share their views about the service.

We carried out this inspection to follow up on warning notices we issued to the provider in respect of the requirements relating to workers and assessing and monitoring the quality of service provision. We had told the provider and manager that the service must be compliant with these notices by 03 March 2014.

Prior to our inspection we reviewed all the information we had received from the provider. We used a variety of different methods to help us understand the experiences of people residing at the home because they had complex needs which meant they were not all able to tell us about their experiences.

We spoke with five people who used the service and the registered manager. We also looked at some of the records held in the service including the care plans for six people. We observed the support people received from the staff through our Short Observational Framework for Inspection methodology (SOFI).

We considered our inspection findings to answer questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

Is the service safe?

We found the systems the manager and provider had in place for identifying and managing maintenance of the premises and ensuring equipment safety were working as required to ensure the safety of people who used the service.

We found that the manager and provider had complied with our warning notice and the recruitment procedure ensured new staff were safe to work with vulnerable adults.

Is the service effective?

We observed how people who used the service were treated with dignity and respect at all times. People told us that they were happy with the care that had been delivered and their needs had been met. It was clear from our observations that staff had a good understanding of the people’s care and support needs and that they knew them well. One person told us. “They look after me here, they spoil me. The food is good; I can have what I want. “

Is the service caring?

We found the service to be caring, as through our observations throughout the day of the inspection, we saw that people were supported by caring, patient, and considerate staff. We observed staff asking people to make choices in relation to their day to day activities, which included their food preferences and what activities they wanted to take part in. All observed interactions showed that the staff were proactive in obtaining consent from people who used the service.

Is the service responsive?

People told us they could do things that were important to them. One person told us, “Staff look after me very well. The food is good and they come and ask you before the meal [what you would like to eat]. Staff help me with washing, dressing and bathing. I’ve been out on a trip. I also do some activities such as art and drawing.”

Is the service well-led?

We found that the manager and provider had partially complied with our warning notice and were taking action to ensure their systems to assess and monitor the quality of the service provided were more effective. Further work to improve and sustain the quality of the service was required.

We were concerned that people's needs were not always assessed and care and treatment was not always planned and delivered in line with their individual care plan. We found that care was not always being delivered to ensure the safety and welfare of people.

We found the systems the provider had in place for identifying and managing the maintenance of the premises was not working as required and was not ensuring the safety of people who used the service. We found that people who used the service, staff and visitors were not protected against the risks of unsafe or unsuitable premises.

We found that people were not cared for, or supported by, safely employed and suitably qualified, skilled and experienced staff.

We found the provider did not had an effective system in place to assess and monitor the quality of the service provided and to identify, assess and manage risks relating to the health, welfare and safety of people who used the service and others. We also found the provider failed to act on reports from the commission regarding compliance with the regulations.

We found areas of concern in relation to other outcomes of the essential standards of quality and safety. The registered manager or provider had not identified these areas of concern.

We carried out this inspection to follow up on a warning notice we issued to the provider in respect of the care and welfare of people who use services. We had told the provider and manager that the service must be compliant with the notice by 19 September 2013.

We found that people did not always experience care, treatment and support that met their needs and protected their rights.

The provider was not fully compliant with the warning notice.

We spoke to three people who were using the service. They told us the staff who supported them were generally respectful. One person said, “The staff are good. They have told me they are here to monitor my needs”. Meal choices and activities were publicised on a board within the home.

Whilst the care plans we looked at had been updated they had not been signed by the person using the service and there was no evidence to demonstrate a relative had been involved.

Care plans provided guidance about how to meet the individual’s needs, however the low staffing levels within the home meant there was a risk that people’s needs were not consistently met.

We found people were safe living in the home. People told us they felt safe with the support they were being provided. One person said, “I feel safe.”

One member of staff said, “There are not enough staff." On the morning of our inspection staffing levels were insufficient to meet the needs of people using the service.

We found staff received regular documented supervisions; however some staff had not received appropriate training. One member of staff said, “I have not had food hygiene training and fire training. I was told what to do in the event of a fire in my induction. I do have an NVQ”.

The provider took steps to assess the quality of the service being provided.

Records of people living in the home had been updated; however they were not stored securely.

We saw a mixed picture of the care provided.

One person told us that when they were not well, although staff tried to meet their needs, the staff seemed to be too busy to spend much time with them.

We spoke with three people who lived at the home. Each of them said that staff helped them with their care and supported their needs most of the time.

One person told us, “I am treated like a fellow adult by staff. They ask me what I would like and allow me to choose the times that I need help from them. I am asked if I am ready to be assisted to get up when I am in bed. I am not rushed by them”

Three people told us they felt safe living at the residential home.

We spoke with five people who were using the service. Two people told us they were happy living in the home and were happy with the care. One person said, “I feel I am well cared for here.” We were concerned that people’s needs were not always assessed and care and treatment was not always planned and delivered in line with their individual care plan.

We saw staff interactions with people who use the service were mainly caring and polite. However, there was not enough staff available to meet people's individual needs in the morning or evening. We saw the majority of people sitting passively in their chairs in the lounge.

We found the systems the provider had in place for identifying and managing maintenance of the premises and ensuring equipment safety was not working as required and was not ensuring the safety of people who use the service.

We found staff were not always being recruited safely with a number of staff files having gaps in the recruitment procedures which should be in place to ensure staff are safe to work with vulnerable adults. We found staff were not being fully supported or trained to deliver care appropriately or safely.

We found there was a lack of audits in place to monitor the quality of the service being delivered. We found areas of concern in relation to other outcomes of the essential standards of quality and safety. These areas of concern had not been identified by the registered manager or provider.