Iceni House

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

During our assessment we found the manager was open and willing to provide and give feedback in a timely way. They realistic in their expectations about where they were in improving the service having inherited a service which was rated requires improvement. Staffing was an issue in terms of both recruitment and retention and culture. Relatives described the manager as visible and responsive, and relatives respected their hardline approach in improving care and dealing with staff who were underperforming or not demonstrating the right values. Whilst we recognized improvements in every aspect of the business, we did have concerns about people’s experience and how this was impacted by staffing levels and, or staff not all working effectively. A number of newer staff were in post or new to their senior role and were developing and learning in these roles. More evidence of training would be advantageous to demonstrate staff had the skills to meet the increased levels of dependency that staff described. Staff felt their initial training was good but the over reliance on eLearning did not consider the individual learning styles of staff . Audits were in place to measure people’s experiences and improve their care and feedback was mostly positive. but we had mixed feedback from staff around staffing levels and the impact this had on people’s experiences and safety. We saw limited information about how people could influence their care particularly when most of them living with advanced dementia. Audits viewed did not address some of the issues we identified during our site visit, such as gloves left out, poor dining room experience and poor recording of people’s daily care needs such as food, fluids etc. The service has improved but improvements were not firmly embedded or sustainable without careful admissions and consideration to staff competencies and numbers of staff to deliver safe care. Holistic care has improved with better partnership working.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager has ambitious plans to make this service outstanding but has faced multiple challenges in their time as registered manager. We were assured that there was improved communication across the home and with outside agencies and that staff felt floors were running more effectively. Staff were being rotated according to the needs of the service. Some staff commented that not all staff were team players and some relatives having concerns about continuity of care and support when there was a regular reliance on agency staff. However, agency numbers were reducing, and core teams were growing stronger. The manager had a clear communication style which most appreciated although some found this difficult. However, all staff said the senior team were approachable particularly unit heads. Staff spoken with did feel the service was going from strength to strength with a shared culture. Relatives told us staff worked well together, one said, “they work together well. The teamwork is there from the laundry, kitchen, and the carers. They all have the same philosophy; we are in the resident’s home, and they all want to make sure that the residents are well looked after. They are a cohesive group; I have never seen a cross word between any of them.” Another said, “They usually have 2 staff doing the activities. When I hear them talking, they seem to be working together. The Manager is good at supervising and seeing what is going on. He can seem a bit controlling but it is a good thing. He walks the floor, so he is aware of things.”

The recruitment processes were sufficiently robust and helped ensure only suitable staff were being employed and had a genuine interest in working in the care sector. Training was being developed in terms of identifying champions based on staff’s interests and talents. Staff reported induction, supervision, and time to talk was appropriate to their needs and stated management was visible.

Feedback about leadership was mostly positive and staff recognised improvements that had been made. Staff identified that across shifts tensions had existed, but this was improving and unit managers across the three shifts as well as heads of care and seniors meant the team were effectively managed. Domestic staff were headed up by housekeeping and the service had its own maintenance team. Wellbeing staff enhanced the care and support given to people, but we felt they were spread too thinly across the home. There were 5 well being staff which included the team leader. They covered 7 days a week and there were usually 1 based on each floor. They told us they supported care staff especially around mealtimes ect and core times of the day and said it was difficult to engage everyone in activity without support from care staff.

The registered manager had knowledge of people using the service and completed walk arounds. They also had a good oversight of the health and social care landscape and were instrumental in making appropriate referrals and ensuring peoples health care needs were met. We felt during our site visit that recording needed improvement and some staff said to us there was a lot of duplicate recording which was both time consuming and unnecessary. The service intended to move away from paper records in favour of a digitalised records system which should improve efficiency.

The majority of staff clearly understood safeguarding processes and what and when they should report incidents. Staff also understood the whistle blowing policy and felt they could approach unit managers, the manager or nominated individual to have their say and most felt concerns were acted upon. However, during our inspection, we felt not all staff were necessarily vigilant or had sufficient oversight of people’s care, neither did management check in on the shift to make sure it was running effectively. Staff did not escalate concerns in a timely way. Relatives told us they felt more empowered to speak up and had the opportunities to do so.

Around the service was information about how to complain and or raise concerns. Relatives told us the manager went out of his way to make them all aware of how to raise concerns and who they could contact if they were unhappy with their initial responses. Suggestion boxes enabled staff, and or relatives and visitors to raise concerns annonomously if they wished. The service did not have any volunteers but the manager had said they had tried and had since the inspection identifed two possible volunteers. Some people were without regular input and support from families so we were concerned their voices may not be heard. For example, we spoke with one person who raised concerns about their care and had not told anyone about it. When we raised their concerns with the manager, they immediately tried to address them. Another person told us they were frightened by people coming into their room and staff’s response had been to shut their door. This seemed an inadequate response to their concerns. The manager advised us several staff were trained mental health first aiders and were there to support staff.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Feedback from staff and leaders was mixed. The manager told us what they had achieved since coming into post and openly shared information. They were regularly supported by a nominated individual who carried out observations and audits. Most staff told us the manager was effective in his role and gave them the support they needed and was quick to address issues within the service. However there were pockets of staff who felt issues were not addressed such as staffing levels which was impacting on the care and support they could provide. Most relatives told us under the current management arrangements things had improved but a number of relatives raised concerns and did not feel they were listened too. At a recent meeting a relative felt at odds speaking out about the care their family member had received. The manager had issued surveys last year as part of their overarching quality assurance but had received a poor return so it was difficult to analyse the outcome. Reasons were given for why our observations on the day of the site visit were poor but we did not accept this was a one off because of feedback we had collated prior to the site visit including concerns about care, culture and staffing. We have rated the service requires improvement for most of the evidence categories we have looked at and identified breaches of regulation.

We were not fully assured of the processes, governance, and oversight, helped to determine if people were getting good standards of care in line with their needs. Whilst we were satisfied people were receiving good clinical care, we had concerns about people’s wellbeing and whether their expectations of care were being met or whether staff advocated for people where they had limited influence on the care provided. Whilst we accept things had improved within the service people had experienced variations in their care and did not yet receive consistently good care. Our observations from our site visit were negative with staff not pulling together or consistent in their approach when responding to people’s needs. For example, we identified one member of staff who took time to reassure and explain to people whilst another member of staff chose not to speak to the person directly. People needing support had to wait which did not uphold their dignity. We observed people unshaven, unkempt, and observed staff slow to react when a person suffered from incontinence. Records did not show how care was always delivered in a timely way or where a lack of care such as refusals of care were followed up to ensure the persons needs were met. Staffing levels were not adequate on the day of inspection and there was inadequate oversight of this. Although explanations were provided as to why the Pickenham suite was running on less staff than usual , feedback from staff collated prior to the inspection indicated wide concerns about staffing levels. From the evidence we collated we identified a breach of regulation 17: Good Governance of The Health And Social Care Act 2008 ( Regulated Activities )

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Whilst we recognize improvements in some areas this was by no means universal and speaking to the manager and nominated individual we were aware of the pressures they were under following concerns and actions from a recent whistle blower. This said the priority was for people using the service to have a consistent service which met their needs. The manager was keen to impress on us that he was on the floor and oversaw staffs practice. He had also put in place a senior management team on each floor and on nights which staff and relatives told us worked well. The manager was carrying out staff supervisions and looking to improve and develop staff. Staff champions were being created to enhance staff roles and utilize staffs skills and interests. The manager was keen to develop the senior leadership team and told us 2 of the senior management team held NVQ5, and other were working towards higher qualification in care and management. In addition the senior team completed enhanced safeguarding training full day course. Some staff were trained in the verification of death and other key skills such as insulin administration which required annual competency checks to be completed. This demonstrated the home worked in partnership with its health counterparts. Action plans were in place to identify and act on improvements necessary but actions identified were not fully in line with our findings .

Opportunities to improve and embed a more positive culture were embraced by the registered manager who was a registered nurse of long standing and keen to impart his knowledge to staff and support them on their journey. The nominated individual was there regularly and supported the home in line with its action plans and reviewed and developed audits to identify improvements required. They worked alongside partner agencies and had developed key competencies in which to measure their performance by. The manager was implementing a National institute for clinical excellence (NICE) safeguarding audit as part of their governance framework. This will ensure staff have the necessary competencies and are able to support people appropriately within human rights legislation and enhance people's experiences who may experience emotional distress. The majority of the staff had completed dementia training to help them support people effectively.