Working at Ivy Gate Lodge

No permanent on-site manager and inconsistent leadership leaves staff feeling unsupported.

Inconsistent management had negatively affected the culture of the staff team. Staff explained they often felt unsupported in their roles due to lack of effective leadership. One of the registered managers had recently left their post. The second registered manager was also the nominated individual. They were not based at the service.

Risks to residents not managed properly, like not supervising someone who poses a danger to others and not updating accident records after falls.

People were exposed to risk of harm as control measures to manage risk were not always followed. For example, a person's care plan stated they should be observed in the lounge as they posed a physical risk to others. Records showed this person was involved in multiple incidents. 2 people had experienced falls and their risk assessments had not been updated.

Staffing levels are enough but not deployed well, so response times can be slow and agency staff not always briefed on resident needs.

Systems were not always effectively implemented to ensure the safe deployment of staff. People and their relatives told us they did not feel the staffing levels were safe. One person told us, 'I need help as I can't walk too well but they don't come quickly when I press the buzzer [staff] are very busy'. An agency staff member was not fully informed about people's care needs before being deployed.