CQC report explained · a nursing home
What the CQC found at Island Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2022
Island Court Care Home is rated Requires Improvement, with Safe rated Inadequate and serious concerns about safeguarding, risk management and dignity.
Inspectors made an unannounced visit on 17 and 18 August 2022. They spoke with people, relatives, professionals and staff, and checked care plans, medicines records, recruitment files and management records.
The home was not always safe. Inspectors found weak responses to safeguarding concerns, poor infection control, gaps in falls and choking risk management, and delays when people needed help. People were not always treated with dignity or given consistent, compassionate care.
The other four areas were rated Requires Improvement. Care planning, food, healthcare access, activities and medicines had some strengths, but staff training, consent assessments, involvement in care and quality checks were not consistent.
The overall rating means the home must make significant improvements. The previous overall rating was also Requires Improvement, while Safe and Effective fell from Good to Inadequate and Requires Improvement.
Medicines
People received medicines safely. Staff had medicines training, competency checks were used and regular audits were in place.
“People at Island Court Care Home were receiving their medications safely.” from the report
Food and health support
People spoke positively about the food and were offered choices. Dietary needs were recorded, and the home sought healthcare support when needed.
“Care plans contained details about people who required specialist diets.” from the report
Personalised activities
Some activities were adapted to people's interests and abilities. People were also supported to take part in activities in the local community.
“Activities were organised for individuals and groups, taking into account people's preferences.” from the report
Cultural and religious needs
The home recorded people's cultural and religious preferences and arranged opportunities to practise religion at the home and in the community.
“The provider arranged for people to practice their religion both within the service and out in the community.” from the report
Healthcare access
People and relatives said healthcare was accessed when needed. Records showed referrals and regular appointments were arranged.
“People and relatives said people were supported to access healthcare services as they needed.” from the report
Safeguarding failures
seriousAllegations of abuse were not always reported or investigated properly. Serious incidents were sometimes not reported to external agencies, and actions to reduce further risks were not always taken.
“Allegations of abuse weren't always reported or investigated.” from the report
Infection control and risks
seriousInspectors saw masks worn incorrectly or not at all, soiled equipment and cutlery, and poor analysis of falls. A person at risk of choking did not receive immediate help.
“We were not assured the provider was using Personal Protective Equipment (PPE) effectively and safely.” from the report
Dignity and compassionate care
seriousPeople did not always receive respectful care. Inspectors observed heavily soiled clothing, undignified language and a distressed person being ignored when asking for help.
“People did not always receive compassionate care that upheld their dignity.” from the report
Consent and capacity
seriousCapacity assessments were not always completed when needed, and some staff did not understand people's DoLS arrangements or the relevant legal requirements.
“People did not always have capacity assessments completed when it was necessary to do so.” from the report
Staffing and training
needs fixingPeople and staff said there were not always enough staff, particularly on the nursing unit. A significant proportion of staff had not completed some relevant training.
“Staff members consistently told us there weren't enough staff, particularly on the nursing unit where people required more support.” from the report
Limited engagement
needs fixingPeople spent long periods without meaningful engagement and were sometimes left in communal areas without staff present. The home was recruiting a full-time activities worker.
“People spent long periods of time without engagement.” from the report
- 01What action has been taken to ensure every safeguarding allegation is reported, investigated and followed up?
- 02How are falls, choking risks and serious injuries now recorded, analysed and used to prevent repeat incidents?
- 03What checks show that staff are wearing PPE correctly and keeping equipment, cutlery and dining areas clean?
- 04How do you make sure capacity assessments and best-interest decisions are completed when needed?
- 05What has changed to improve staffing on the nursing unit and provide more meaningful activities?
This was an unannounced inspection prompted by concerns about safeguarding incidents and accident investigations, and it assessed all five key questions. This explanation was written from the published report of 8 December 2022 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, November 2021
Rated Requires Improvement overall; safe and effective care was rated Good, but records and family involvement needed improvement, and the home had just left Special Measures.
This was an unannounced inspection on 4 October 2021. Inspectors spoke with people living in the home, relatives, staff and professionals. They reviewed care records, medicines records, staff files and management records.
The home was rated Good for Safe and Effective. Inspectors found enough staff, safe recruitment, suitable medicines management, infection control and staff training. People were protected from abuse and avoidable harm.
The home was rated Requires Improvement for Well-led. Some care records lacked important information, including how non-verbal people communicated and how often people with skin damage needed repositioning. People and relatives were not always involved in care plans or kept informed about changes.
The previous overall rating was Inadequate and the home had been in Special Measures since October 2020. Inspectors found improvements and said the home was no longer in breach of regulations or in Special Measures.
Safety
Staff understood safeguarding and knew what action to take if they suspected abuse or avoidable harm.
“People were protected from potential abuse and avoidable harm.” from the report
Medicines
Medicines were given safely by trained staff. Records and stock checks were accurate at this inspection.
“People received their medicines when they needed them, and medicines were managed safely by suitably trained staff.” from the report
Staffing and training
Inspectors found enough staff and safe recruitment checks. Staff received training, supervision and ongoing support.
“There were sufficient numbers of staff to meet people's needs.” from the report
Respect and dignity
People and relatives said staff were kind, respectful and helped people remain independent and connected with others.
“People and their relatives told us they felt well cared for by staff who treated them with respect and dignity” from the report
Improvement since the last inspection
The home had addressed earlier problems with medicines records, blood sugar monitoring and care plans. It was no longer in breach of regulations.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Incomplete care records
needs fixingSome repositioning charts had gaps for people with pressure damage. Some communication plans did not explain how non-verbal people showed consent or how they felt about their care.
“Care records did not always contain enough information.” from the report
Limited involvement of relatives
needs fixingPeople and relatives were not always involved in developing assessments and care plans. Some relatives were not told about changes in health conditions.
“We found people and their relatives were not actively involved in the development of assessments and care plans.” from the report
- 01How do you now record the communication needs, consent and preferences of people who cannot speak?
- 02How do you check that repositioning charts are completed correctly for people at risk of pressure damage?
- 03How will my relative and I be involved in developing and reviewing their care plan?
- 04How will you tell relatives promptly about changes in a person's health or care needs?
- 05What checks are now in place to make sure the improvements identified since the last inspection continue?
This was a focused inspection prompted by concerns about safeguarding, recording and discharge practices; ratings were given for Safe, Effective and Well-led, while Caring and Responsive were not rated. This explanation was written from the published report of 19 November 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.
Every inspection of Island Court Care Home
5 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2021Requires improvementup from InadequateSafe: GoodEffective: GoodWell-led: Requires improvement
- September 2020Inadequatestayed InadequateSafe: GoodWell-led: Requires improvement
- December 2019Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2020
Registered with the Care Quality Commission on 18 February 2020.
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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