Archived: Ixworth Dementia Village

Updated 9 June 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by three inspectors, on the first day. One of those inspectors specialised in medicines. On the second and third day of the inspection, two inspectors visited the service. The third inspection visit took place during the evening.

Service and service type

Ixworth Dementia Village is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Ixworth Dementia Village is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

The nominated individual was present on the first two days we inspected. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Notice of inspection

This inspection was unannounced on all three days.

What we did before the inspection

We reviewed information we had received about the service. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We used all this information to plan our inspection.

During the inspection

We spoke with two people who used the service and four relatives about their experience of the care provided. We reviewed seven care plans and nine people’s medicine administration records. We spoke with 18 members of staff which included care staff, the cook, the nominated individual, the registered manager, provider and two business support managers.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.

Updated 9 June 2023

About the service

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.