CQC report explained · a residential care home
What the CQC found at Icknield Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People told inspectors they felt safe and there were enough suitably recruited staff. However, medicines were not always stored at the correct temperature, and some medicines care plans were missing or incomplete.
- Effective?
- Good
- People's needs were assessed and staff had suitable training and supervision. People received support with nutrition, healthcare and consent in line with the law.
- Caring?
- Requires improvement
- This question was not covered by this focused inspection.
- Responsive?
- Requires improvement
- This question was not covered by this focused inspection.
- Well-led?
- Requires improvement
- The management team was visible, open and positive, and worked with outside professionals. However, audits did not always lead to timely corrections, and care records were not consistently accurate, complete or up to date.
What inspectors found, October 2021
Rated Requires Improvement; inspectors found progress since an Inadequate rating, but medicines and care records were still not reliable enough.
This was an unannounced focused inspection on 28 September 2021. Inspectors checked Safe, Effective and Well-led. They spoke with people, a relative, staff and healthcare professionals, and reviewed care, medicines, recruitment, training and management records.
The home had improved from its previous Inadequate rating and was no longer in special measures. People said they felt safe, staffing and recruitment were suitable, and the home worked well with healthcare professionals. Staff training, nutrition support, infection control and consent arrangements were rated Good under Effective.
However, medicines were not always stored at the right temperature and some medicines care plans were missing or lacked important instructions. Care records were sometimes contradictory, incomplete or not updated quickly enough. These problems meant the home remained in breach of regulations and was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement.
Improvement since the last inspection
The home improved from Inadequate and left special measures. Inspectors found that some earlier problems, including risk management, had been addressed.
“The service is no longer rated as inadequate overall or in any of the key questions.” from the report
Staffing and recruitment
There were enough staff to support people, and recruitment checks were carried out before staff started work.
“People were supported by staff who had been recruited using robust processes.” from the report
Training and healthcare support
Staff received training and supervision. The home worked well with GPs, the local authority and other healthcare professionals.
“People were cared for by staff who received appropriate support, training and supervision.” from the report
Infection control
Inspectors found good cleaning and hygiene practices, with suitable testing and protective equipment arrangements.
“People were protected from the risk of infection at the home through robust cleaning and hygiene practices.” from the report
People felt safe
People and relatives told inspectors they felt safe. Staff understood how to recognise and report abuse.
“People and their relatives told us they felt safe at the home.” from the report
Medicines were not managed reliably
seriousSome medicines were not stored at the temperature required by the manufacturer. Some people did not have a medicines care plan, or the plan did not explain important timing or end-of-life instructions.
“Medicines were not always stored at the appropriate temperature.” from the report
Care records were inconsistent
seriousSix of the 10 care records reviewed contained contradictions or needed improvement. Risk scores and care plans were sometimes different, blank or not updated promptly.
“Records we viewed were not routinely consistent, accurate and complete.” from the report
Short-term care plans were less complete
needs fixingPeople staying temporarily at the home had more limited care plans. Inspectors recommended that the provider seek advice about care planning for short-term admissions.
“However, where people were staying temporarily (on respite) at the home, we found the provider used a more limited and less comprehensive care plan.” from the report
Audits did not always lead to quick action
needs fixingAudits identified some problems, but the actions needed to correct them were not always completed promptly.
“We found whilst they did identify where improvements were needed, the actions to rectify this was not always completed in a timely manner.” from the report
- 01How are you now checking that medicines are stored at the correct temperature every day?
- 02Does every resident, including people admitted recently or for respite, have a complete and person-centred medicines care plan?
- 03How do you make sure care plans and risk scores agree with each other and are updated promptly after a change or incident?
- 04What training has staff received on calculating Waterlow and MUST scores, and how do managers check that it has worked?
- 05What progress has been made on the action plan submitted to CQC after this inspection?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not covered and their ratings were not given in this report. This explanation was written from the published report of 26 October 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, September 2020
Rated Inadequate and still in special measures; inspectors found people at risk from unsafe care, medicines problems and weak management systems.
This was an unannounced focused inspection on 29 and 30 July 2020. Two inspectors and a pharmacy inspector reviewed information, spoke with staff and managers, observed care and medicines, and checked records. They also contacted relatives after the visit.
The home was rated Inadequate for Safe and Well-led. Inspectors found incomplete records about repositioning, food, fluids and weight. Staff did not always follow healthcare professionals' advice about pressure ulcers. There had also been a high number of reported medicines errors, unsafe medicines practice and inaccurate controlled drugs records.
The home had enough staff, safer recruitment checks and good infection-control arrangements. However, management checks were not effective, earlier warning notices had not been met, and improvements had not been sustained. The overall rating remained Inadequate and the home remained in special measures.
Staffing levels
Inspectors found enough staff were deployed to meet people's needs, and recruitment checks were completed before new staff started.
“The provider had employed senior staff to assist with the ongoing monitoring of the units.” from the report
Infection control
The home was clean and staff used the correct protective equipment. Inspectors said government infection-control guidance for the Covid-19 pandemic was being followed.
“The service was cleaned to high standards and we saw correct personal protective equipment (PPE) was used throughout the service.” from the report
Commitment to improvement
After the inspection, the provider said it had arranged external support and was developing an action plan to address the concerns.
“Following the inspection, we met with the provider and they have engaged external support to help drive improvement at the service.” from the report
Risks were not managed
seriousCare records were incomplete or contradictory, and staff did not always follow instructions from healthcare professionals. This included concerns about catheter monitoring, bowel care and pressure ulcers.
“People were not always supported in a way that ensured they received safe care and mitigated any risks of avoidable harm.” from the report
Medicines safety
seriousThe report refers to more than 40 medicines errors between January and March 2020 and more than 40 additional errors reported between May and July. Inspectors also saw poor hand hygiene and inaccurate controlled drugs records.
“People continued to be placed at risk from unsafe medicines management.” from the report
Poor monitoring of food and fluids
seriousFood and fluid charts had gaps, and weights were not always recorded for people at risk of malnutrition. Inspectors could not always tell whether people had eaten or had received the monitoring they needed.
“Food and fluid charts contained gaps and people's weight was not always monitored where there was an identified risk of malnutrition.” from the report
Weak management checks
seriousAudits did not show clear actions or outcomes. Management systems failed to identify or deal with important shortfalls, and previous warning notices had not been met.
“The provider had not been able to make or sustain improvements since the last inspection” from the report
Communication concerns
needs fixingSome relatives and staff did not feel able to raise concerns openly. Inspectors also found examples of poor communication with relatives about important matters affecting people's care.
“People using the service, their relatives and staff did not always feel able to openly raise and discuss concerns and felt communication could be better.” from the report
- 01What changes have been made to prevent medicines errors, and how are medicines records and controlled drugs now checked?
- 02How do you make sure staff follow healthcare professionals' instructions about pressure ulcers, repositioning and skin care?
- 03How are food and fluid charts and weight records checked each day for people at risk of malnutrition?
- 04What actions from the improvement plan have been completed, and what evidence can you show that they are working?
- 05How can residents, relatives and staff raise concerns safely, and how will you keep families informed about important changes to care?
This was a focused inspection of Safe and Well-led only; the other three key questions were not inspected and their previous ratings were used. This explanation was written from the published report of 23 September 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Icknield Court
7 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- October 2021Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2020Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- January 2020Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- August 2018Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2015Goodstayed GoodEffective: Good
- January 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 29 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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