Archived: Iceni House

Updated 8 October 2025

Date of assessment 21 October 2025 to 19 November 2025. Iceni house is a care home that can accommodate up to 75 people for residential or dementia care. At the time of our assessment there was 60 people living in the service. We carried out our assessment due to concerns over managerial oversight in the service and an increase in safeguarding concerns.

We conducted 2 unannounced site visits. We observed the environment, spoke to staff and people living in the service. We spoke to some healthcare professionals and relatives on site and following our site visits.

We found the provider was in breach of the legal regulations relating to person-centred care, safe care and treatment, consent, good governance and staffing.

We found the service was unclean and not well maintained. People were not supported to maintain their personal hygiene and were not supported appropriately during mealtimes. We identified fire safety concerns. Peoples care records did not reflect their needs and preferences and had contradicting information recorded in them. Care records and risk assessments were not followed as advised and people were not actively monitored where there were known risks. This put people at risk of harm.

Staff were not supported appropriately and did not have regular or timely supervisions or appraisals. There was no regular out of hour spot checks conducted on the service to assess the quality and culture of the workforce. We found there was a closed culture. There was a lack of governance oversight and poor systems and processes in place. The provider did not appropriately assess and monitor what was happening in the service and this contributed to the closed culture we identified. Audits were not effective in identifying concerns to enable them to be rectified.

At the time of our assessment, there was a new management team that had been in place for the last 8 weeks. They had identified some of the concerns that we had found and had begun to review their systems and processes to implement new ways of working. These were not embedded within the service at the time of our assessment. We observed where we gave feedback on concerns we had identified, actions were taken to try and rectify them.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

Updated 8 October 2025

Throughout our assessment we gained mixed feedback from 14 people living in the service. Some people were not happy with the care they received and had to wait a while for staff to respond to their needs, they were not supported to go outside and felt action was not always taken when they raised concerns. Some of the feedback we received from people was “staff do a reasonable job. But they are busy. I use my walker to get out of my room. I do not see them much.” And “I do not get offered shaves which is important to me.” However, some people were happy with the care they received, 1 person told us “Yeah, I'm happy with the care I receive. I'm a person that likes to get up early and they support me with this.” Another person said, “Yes, very happy and they've done an awful lot for me, I was a wreck when I came in.”

We received mixed feedback from 11 relatives. Some relatives were not happy with the hygiene standards people received and management oversight was a concern. A relative told us, “The care is ok, but hygiene standards are not my hygiene standards. I will often come, and my [relative] is in dirty stained clothes and looks unkempt”. Another told us “Continuity of management would be good.” Some relatives were happy with the care people received; some feedback we received was “things have improved, and I find it quite good, the care is good and the state of the home is improving” and “staff treat [relative] well, main staff are brilliant with [relative]”

We also completed a Short Observational Framework for Inspection (SOFI). A SOFI is an observation we conduct that helps us identify the experience of people who cannot talk to us. We observed staff interacted nicely with people and communicated with people when they were being supported. However, at mealtimes, we found people were not consistently sat up appropriately when being assisted with their meals.