Iceni House

Updated 3 November 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors, one medicines inspector and an Expert by Experience.

An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Iceni House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Iceni House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 06 September 2022 and ended on 22 September 2022. We visited the service on 06 and 07 September 2022.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection

During the inspection we spoke with 13 staff, including the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke to nine people who used the service and eight family members of people receiving support. We reviewed eight peoples care records, 13 medicine administration records (MAR) and two staff records. We also reviewed other records, including policies and procedures, relating to the safety and quality of the service. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 3 November 2022

About the service

Iceni House is a residential care home providing personal care and support to 57 people aged 65 and over at the time of the inspection. The service can support up to 75 people. The care home consisted of two units, one on the ground floor and one on the first floor of the building. Each floor providing single accommodation for people requiring residential or more specialist dementia care.

People’s experience of using this service and what we found

Audits that had been implemented were not effective in all areas and did not ensure care records were accurate and detailed. Not all environmental risks had been thoroughly assessed to ensure people were safe from potential harm.

People did not all consume their breakfast at a suitable temperature impacting on this experience.

The management team had made improvements to the support being offered at this service since our last inspection. Although some areas required further strengthening the management team had a development plan in place to further improve the compliance of this service.

People’s medicines were stored and administered safely. People received their medicines on time and as prescribed by healthcare professionals.

People and their relatives felt the care provided had improved since our last inspection and that staff were approachable.

People and their relative's feedback was regularly sought, and they were involved in shaping the support offered at the service.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 1 February 2022) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made however the provider remained in breach of regulation.

Exiting special measures

This service has been in Special Measures since 01 February 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We carried out an unannounced focused inspection of this service on 13 December 2021. Breaches of legal requirements were found in relation to safe care and treatment, staffing and good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Inadequate to Requires Improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Iceni House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified a breach in relation to good governance and oversight at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider and request an action plan following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.