Archived: Ixworth Dementia Village

Ixworth Dementia Village is a residential care home providing accommodation and personal care for up to 24 people. At the time of our inspection there were 23 people using the service most of whom were living with varying levels of dementia. The service consists of three houses (Mayfair, Homely and Traditional) which are all on the ground floor.

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

Risks to people's health, safety and welfare were not managed effectively, placing them at significant risk. People's care records were not always person centred and accurate. They lacked information to guide staff in how to meet their needs safely and effectively. When events or incidents had occurred, records did not evidence what action had been taken. There was no evidence lessons were learnt when things went wrong.

Infection control procedures were not always followed to ensure the spread of infection was reduced. There were safeguarding procedures in place however these were not always followed to ensure people were protected from potential harm. Peoples' medicines were not managed safely.

There were insufficient trained or supervised staff to safely meet the needs of people. There was limited support for people to avoid social isolation, follow interests and take part in activities.

The service was not consistently working within the principles of the Mental Capacity Act 2005 (MCA) People had not been supported to maximise their decision making and records lacked detail on the information used to determine people's capacity.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The registered manager had not been supported and enabled to have adequate oversight of the service. Quality assurance systems and processes did not identify or address all of the issues found during this inspection.

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

Rating at last inspection

The last rating for this service was good

Why we inspected

The inspection was prompted in part due to significant concerns we found during an inspection of the other service run by this provider.

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 have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

Following the inspection, the provider took steps to mitigate risks, such as undertaking the voluntary suspension on any new admissions and increasing the staffing levels. They also employed the services of a Health and Social Care Consultant to help them devise and work to an action plan to make the necessary improvements.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, medicines, consent procedures, staffing, nutrition, person-centred care, and governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

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. We will also request an action plan from the provider to understand what they will do to improve the standards of quality and safety.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Ixworth Dementia Village is a residential care home providing accommodation and personal care for up to 24 people. At the time of our inspection there were 16 people using the service most of whom were living with varying levels of dementia. The service consists of three houses (Mayfair, Homely and Traditional) which are all on the ground floor. At the time of the inspection, due to occupancy, only two of the houses were open and in use.

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

Since our last inspection the service had received enhanced support and guidance from the Local Authority and the provider had an action plan in place. Whilst we found there were areas of improvement, this was not sufficient and embedded and further work was required.

Whilst the provider was no longer in breach of some of the Regulations that they were at the previous inspection they remained in breach overall and had failed to take action to ensure potential risks were effectively assessed and mitigated against. This put people at risk of harm.

Staff did not always follow best practice to prevent and control the spread of infections. This put people at risk of harm. We could not be assured medicines were managed safely. Stock counts for people's medicines were incorrect, some protocols for ‘as required’ medicines were missing, and topical creams and ointments were not administered in line with the prescriber’s instructions.

Staffing levels had been improved, there were more staff throughout the day and night to meet people’s needs. Staff were safely recruited. We have made a recommendation about the provider monitoring the staffing levels closely.

People were not provided with enough meaningful activities to ensure they were mentally and physically stimulated. People we spoke with felt there wasn't enough for them to do.

Quality monitoring systems were detailed but were not targeting the right areas to help ensure the safe running of the service. This meant the provider and registered manager could not be proactive in identifying issues and concerns in a timely way and acting on these.

Whilst the meal time experience required improvement, a chef had been employed and the choice of food and the quality of meals had improved. We have made a recommendation about the provider carrying out their own meal time audits to pick up areas for improvement and promote best practice.

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 (report published on 29 July 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 the provider remained in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Leaf Park Dementia Village on our website at www.cqc.org.uk.

Enforcement and Recommendations

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is 'Inadequate' and the service remains in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Ixworth Dementia Village is a residential care home providing accommodation and personal care for up to 24 people. At the time of our inspection there were 12 people using the service most of whom were living with varying levels of dementia. The service consists of three houses (Mayfair, Homely and Traditional) which are all on the ground floor. At the time of the inspection, due to occupancy, only two of the houses were open and in use.

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

Since our last inspection the service had received continued and enhanced support and guidance from the Local Authority. Despite this the provider’s management systems were repeatedly failing to identify concerns and support improvements. This is the third consecutive inspection where the provider has been rated inadequate and there have been multiple breaches of the regulations.

Care plans did not accurately reflect people's needs and they lacked guidance for staff about how to support people’s individual high risk healthcare needs. People were placed at risk of malnutrition and dehydration. We were concerned that people were not safe. We made 3 safeguarding referrals to the local authority during this inspection.

Medicines were not safely managed. Records did not reflect that topical creams and ointments were administered in line with the prescriber's instructions.

There were insufficient numbers of staff available to meet people's needs in a person centred and timely way. The provider took action to increase the staffing levels during the day immediately after our inspection. They did not increase the staffing levels overnight, however. Staff recruitment systems were in place to ensure only suitable staff were employed.

People did not always receive care which was respectful or dignified. People were wearing clothes that were visibly written on in order to identify their laundry. Some of the language used in care plans was disrespectful to people. Some staff were not patient and kind with people.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Decisions were not always made in people’s best interests.

Duty of candour was not complied with. Registered persons must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity. We found the registered manager and provider were not open and transparent. Care records were amended retrospectively. A person living at the care home did not have an accurate reflection of their needs relayed to their family. The provider had not always notified CQC of incidents or accidents which is a requirement of their registration.

The provider failed to develop effective governance and quality assurance systems to assess the quality and safety of the support people received. There was limited oversight of the day-to-day operation of the home and the actions of the registered manager. The lack of effective provider level audits failed to determine trends and themes.

There were systems in place to protect against the spread of infection.

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 (report published on 3 November 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 the provider remained in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service. 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 have found evidence that the provider needs to make improvements. Please see the safe, effective, caring and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement

We have identified breaches in relation to dignity and respect, safe care and treatment, good governance and duty of candour.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found the following examples of good practice.

The service was working with the local authority and health protection teams in managing the COVID-19 outbreak. They had accessed support around medicines, testing and vaccinations.

There was a plentiful supply of personal protective equipment (PPE). Staff had been trained in using it and demonstrated competence.

Staff helped people to maintain links with their family and friends by phone and on-line.

There was weekly testing of staff in place.

Further information is in the detailed findings below.

Ixworth Court Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Ixworth Court Care Home accommodates up to 17 people in one adapted building. During our comprehensive unannounced inspection on 3 April 2019, there were 5 people living with dementia using the service.

People’s experience of using this service:

People were supported by compassionate and caring staff who knew them well.

Systems were in place to help protect people from the risk of abuse and harm.

Staff were recruited safely and received on-going support and training to be effective in their roles. Medicines were managed safely and were available when required.

The environment was clean, and staff followed good infection control practices.

People’s nutritional and hydration needs were met, and they were supported to access healthcare professionals when needed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People’s independence was encouraged, their privacy respected, and their dignity maintained.

People were occupied with meaningful activity and had opportunities to maintain positive links with their community.

People's end of life wishes were documented.

There was a complaints procedure in place and people’s concerns were addressed.

There was an open culture in the service. People using the service, their representatives and staff were asked for their views about the service and these were valued and acted on.

Systems to continuously monitor, assess and improve the quality of the service provided were in place.

Rating at last inspection:

This was the first inspection of the service.

Why we inspected:

This was a planned inspection following registration on 10 April 2018.

Follow up:

We will continue to monitor this service according to our inspection schedule.

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