Archived: Iceni House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment and staffing.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive culture of safety. Lessons were not learnt to continually identify and embed good practice. The service could not evidence that accidents and incidents were investigated thoroughly to identify causes to individual people within the service. The service had a complaints log that showed 5 out of the 7 complaints were the “standard of care” however, these had not been analysed to identify trends or themes and no wider lessons learnt.

We identified that 2 people living in the service had unexplained bruising on a skin integrity report. We could not find any accident or incidents in the previous 3 months involving these people. The service was not aware how these occurred and no other recording of the bruises within their systems. There was no investigation to find how the bruises were caused.

The new management team had recently implemented a lesson learnt process, where they share lessons learnt with the staff. All the people and their relatives that we spoke with knew how to raise concerns. The staff told us about their process for recording accidents and incidents.

The provider worked with people and healthcare partners to establish safe systems of care, in which safety was managed or monitored. We found staff communicated clearly when people were no longer in the service in daily meetings. We spoke to healthcare professionals who felt there had been some improvement in the continuity of care since new management had been in place. One healthcare professional said, “[interim manager] has been very focused on referring pressure wounds and trauma to our service and notifying Care Quality Commission (CQC.) If [interim manager] is unsure, he will always contact us. With the previous managers this did not always happen.”

The provider did not concentrate on improving people’s lives or protecting them from avoidable harm and neglect. We observed the environment and found a person with a high risk of falls, had passive infrared sensor (PIR) either side of their bed to alert staff if they were trying to mobilise unaided. We found one PIR was turned off and the environment was not always safe; action was not always taken when risks were identified.We reviewed people’s records and found that people were not free from avoidable harm. We identified some areas of a closed culture in the service. A staff member told us, “I complete safeguarding training online; I am not aware of any other ways to report a concern apart from going to management.” The new management team identified safeguarding concerns that were not reported and completed these retrospectively. We received mixed feedback from people in the service about safeguarding concerns. 1 person we spoke with said “I got fed up of raising the concerns before” and another person told us “Oh yes I cannot grumble about the staff at all.” People had deprivation of liberty safeguards applications in place where required. Applications that had been authorised had conditions displayed clearly where applicable.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We identified a person at risk of falls had electronic assistive technology in place.. We observed the equipment was turned off while on site. The service had plans to monitor this issue and ensure staff were checking the equipment regularly throughout the day. We reviewed care notes 1 week later and could not evidence the equipment was being checked. In addition, this individual had a fall in this time and there was no evidence the PIR was triggered.

We received mixed feedback from people living in the service, 1 person told us “I had a bell the other week, it went wrong so they gave me this (watch Pendant) If they do not come, I shout. previous manager told me not to do that, and I said if they do not come, I will shout.” A relative told us “I have no idea what they intend to do to reduce the risk of her falling and it would be better if they kept her in the lounge because she’s in her bedroom on her own and she can’t see. I’ve given up with the complaints.”

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We found the environment needed to be refurbished and equipment in the service needed replacing. The service had a fire risk assessment that was completed in October 2024. We found actions that were recommended to be completed within 1 week due to the risks of a fire spreading within the service were still pending. We found Several fire doors had gaps around them which would contribute to the spread of a fire. We found a fire door had a bolt installed on it and it was locked shut in the dining room. Fire exits were not consistently kept clear. No staff had received a fire drill to ensure they could evacuate people safely.

As a result of feedback, the management team ensured every staff member undertook a fire drill and organised for an external contractor to rectify the fire doors and the bolt in the dining room was removed.

The provider did not make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. When we attended site, we were concerned over the staffing levels and culture of the workforce. We observed staff were not visible in the environment, and when people were using their call bells, they were having to wait for times up to 15 minutes to have their needs responded too. However, we attended the following day and noted an improvement on staffs’ visibility.

We received mixed feedback from people, 1 person we spoke with said “you can wait 5 minutes or 5 hours for someone to answer the bell. Short staffed, always worse at mealtimes and bedtimes” a relative said “They do have enough staff, they have wellbeing people at the weekends who do a mixture of activities.”

We found there was safe recruitment checks being conducted although the services policy was not being followed when people were being interviewed. On the 4 personnel files we viewed, candidates were not assessed by scoring, as per policy. Staff had not been receiving regular supervisions and no appraisals had been completed with the staff within the last year.

The provider did not manage the risk of infection. They did not detect and control the risk of it spreading as the environment was unclean and unhygienic. We observed the corridor and dining room walls were stained. We found a chair in a person’s bedroom visibly dirty with marks embedded within the fabric.

There were 2 first aid emergency eye wash stations in the laundry room and kitchen that had a build-up of dust on them. There were several areas in the kitchen that had a build-up of limescale, and some utensils were rusted. When we made the service aware of the utensils they were replaced immediately. Floors were unclean in areas on the service and cleaning equipment was not maintained and cleaned appropriately.

The service completed infection prevention control audits although they were not consistently creating actions where issues were identified. We received mixed feedback with their cleanliness of their environment, 1 person said, “there isn't a day we don't get a cleaner in” and a relative told us “Often [relative] bed can be grubby and need changing.” A staff member told us “We have 2 domestics a day and the care team assist to clean up if they are busy.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs. The service had started a new medication cycle and were on the second day of the cycle when we carried out our inspection. We found discrepancies with newly arrived controlled medication that had not been recorded accurately. We found peoples pro re nata (PRN) medication which translates to when required, was not carried over to the new medication cycle. We found a signature list that had the staff recorded as able to administer medication in the medication room. It was out of date and had a previous registered manager recorded on it who left the service in October 24.

However, the service carries out regular medication audits to identify errors to rectify them promptly. They had a pharmacy audit conducted within the service within the last year and all staff were trained and competent to administer medication. Staff told us the process if they identified a medication error. People were happy with the medications and that they were discussed with them, 1 person told us “We go through it, and the GP comes in regularly, I would not have that treatment in the countryside and get them on the doorstep like here.”