Ingleby Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service was not always safe and has been rated requires improvement. We found 3 breaches of regulation relating to safe care and treatment, specifically medicines management, duty of candour and good governance. Some people said they were included in their care and the management of risks however it was acknowledged this was an area for improvement. There was evidence of appropriate referrals to healthcare practitioners. However, records lacked person centred detail and there was limited evidence of a learning culture. People said they felt safe, and the staff had a good understanding of how to protect people from avoidable harm and abuse. Medicines were not managed safely, and governance and oversight of medicines was not robust. Aside from the medicine treatment rooms the home was clean and infection prevention and control practices were in place. The environment was being improved however staff didn’t understand procedures to follow in emergencies and fire evacuation drills and fire training needed to improve. Safe recruitment processes were in place however there were mixed views on staff deployment. The provider had failed to ensure staff had appropriate and consistent support and supervision.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were positive about the home and the care they received, saying staff were kind and caring. However, their experience was affected by a lack of oversight. A provider oversight audit completed in June 2024 referenced surveys being completed and analysed, however the manager was not able to find these during the assessment. This meant any feedback that had been provided was lost.

Staff did not raise any concerns about the culture of the home, saying the current management team were approachable. However, there was limited evidence of learning as staff surveys could not be found, audits were not effective, and staff supervisions had not been held regularly.

Complaints had been investigated and learning included reviewing admissions procedures and increasing checks on the laundry room. Some records were in place in relation to accidents and incidents, and notifiable safety incidents had been identified. However, the Duty of Candour requires providers to follow a specific procedure as soon as a notifiable safety incident is identified and there was no evidence this was completed. The regional manager confirmed there were no records in relation to Duty of Candour requirements.

People said they was some involvement in care planning, and they had access to health care professionals when needed. However, some people’s experience was affected by the lack of a person-centred approach.

The manager explained the electronic care planning system allowed staff to download and print a ‘hospital pack’ which contained key information about the person should they need to be transferred to hospital.

Positive feedback was received from a visiting healthcare professional.

Care plans evidenced referral processes were in place for contacting other professionals, including Speech and Language Therapy, the falls team, tissue viability and district nursing. However, records lacked person-centred detail in ensuring people’s needs and wishes were met.

People told us they felt safe. Relatives said they were able to raise concerns and felt listened to. One relative shared an example where they had raised concerns for their loved one’s safety and commented they were happy with the outcome, they felt their relative was safe and staff had done a good job in addressing their concerns.

Staff said they had access to policies and procedures and understood how to report safeguarding concerns. They were knowledgeable about possible indicators of abuse. Staff told us they had raised a safeguarding concern recently in relation to unexplained bruising which was investigated by the manager.

We did not observe any concerns during the inspection.

Systems and processes were in place to protect people from avoidable harm. Safeguarding concerns were raised, and notifications submitted. A safeguarding vulnerable adults’ policy was in place and staff had attending training.

Some people were not involved in care planning and risk management decisions. People and their relatives commented that there were regular reviews but not specifically in relation to risk management and safety.

The manager explained people, and relatives are spoken with during the admissions process and resident meetings. They said, “These are done as one to ones and no records are kept. This needs to change. This has been informal.” We did not see any evidence of resident meetings.

Staff were observed keeping people safe during mealtimes. They were aware of people’s risks and worked together to ensure people were safe and comfortable. However, we observed one person used their nurse call bell frequently and staff were not always able to respond due to competing priorities and engagement with other tasks.

Processes were in place to include people, and their relatives, where appropriate in the assessment and management of risks. Some people’s care records evidenced inclusion, however the manager confirmed this as an area for improvement.

People and their relatives felt there was a nice environment, which they felt was well maintained. A relative commented on some improvements that had been made. For example, replacing carpets with hard flooring in public areas. People were impacted by the nurse call alarm system which sounded on both floors.

There was mixed feedback from staff about emergency planning. One staff member said, “I’ve not been told about any plans that are in place.” Another said, “There’s a space key to the church nearby if the emergency required residents to be moved.” This was not detailed within the continuity plan. The regional manager said, “If in doubt staff just ring me.”

We observed improvements were being made and the provider was working through a programme of improvements. Call bells sounded for extended periods of time, and it was identified there were issues with it turning off once staff had responded. Whilst there were some pictorial signs indicating dining room and bathrooms there was limited evidence of consideration to a dementia friendly environment.

Safety checks on premises and equipment were completed, and risk assessments were in place. However, not all staff had taken part in a fire evacuation drill. This had been identified as an action since February 2024. The manager said one had recently taken place and this was improving. The nominated individual said the nurse call system hadn’t been raised as a concern, but it would be looked into.

There were mixed views from people and relatives about staffing levels. Some comments included that the staff team was stable with a few agency staff used, whilst other comments included, “I don’t think they have enough staff, you have to wait for certain things, like the second staff member for the hoist.” People’s experience was affected due to staff not receiving consistent support and supervision.

Staff feedback in relation to staffing was also mixed with some saying there was enough, and others commented they could use more staff. One staff member did say, “We raised staffing with management, and they were allowed extra staff. There’s been a few new starters, and they seem to pick things up quickly.” Staff also commented that they had not had regular one to one support meetings or an annual appraisal. The manager agreed this was lacking, however they said they had a plan in place to address it.

Staffing levels were appropriate to meet people’s needs. The mealtime experience was not rushed, and a high number of people were supported to have meals in their rooms. However, observations indicated that due to people spending most of their time in their rooms the deployment of staff needed to be reviewed to ensure person-centred care could be provided.

Safe recruitment processes were in place. DBS checks were completed however previous qualifications were not evidenced by certificates and there were no staff photos in files. Staff said they felt supported by the current management team. However, staff support meetings had not taken place in line with the providers policy. Some staff had received one support meeting during 2024, whilst 13 of the 34 staff on the support matrix had received no supervision during 2024. Some key training had been identified as needing to improve, however significant numbers of staff were overdue for training in moving and positioning of people, fire awareness and fire drills.

People and their relatives did not share any concerns around infection prevention and control. However, people’s experience was affected to a lack of oversight in relation to cleanliness in medicine rooms.

Staff commented that the home was clean. The manager told us extra domestic staff had been recruited and there were 4 staff in the home each day. We did not observe this during our inspection.

Communal areas within the home were clean and tidy. Domestic staff were present and attentive. However, the medicine treatment rooms were not clean and needed attention. Staff were observed to wear Personal Protective Equipment (PPE) appropriately.

IPC audits were completed, however in April 2024 and June 2024 they showed a deterioration in standards. Action plans were in place but not all actions had identified people responsible for completing actions and some actions hadn’t been signed off as completed. For example, tumble mats and bed bumpers were identified as not being fit for purpose and not all pull cords had plastic coverings. During the inspection we noted that plastic coverings were in place on nurse pull cords.

People were not always supported to receive their medicines as prescribed. Work had recently been undertaken to improve the ordering of medicines, so people did not miss doses however there continued to be differences between computer and shelf stock balances. People who were prescribed patches did not have accurate and complete records to ensure the patches were rotated in line with manufacturer’s instructions. People’s care plans, including as required protocols did not always contain enough person-centred information to support staff in the safe administration of medicines. People who had medicines prescribed as a variable dose did not always have protocols in place to support staff in the safe use of these medicines.

Staff told us improvements had been made with medicines processes. They said medicines processes were improving as they now had medicines available which had been a problem recently. It was not clear from staff training and competency information provided to us when staff training had occurred and when competencies had been completed. Managers recognised they had a lot of work to do with medicines and a new deputy had been employed. In addition, external support had been accessed to help with identifying where improvements were needed.

Medicines were stored securely when we visited the home. Work was needed to ensure items used to assist with medicines administration were thoroughly cleaned between each use and that hand washing facilities were available to staff administering medicines. There was no process in place for the returns of medicines, although the home had identified this, actions had not been taken to mitigate the risk whilst awaiting supplies of waste bins and recording books. Although work had been completed to improve the recording of topical medicines, not all creams had body maps in place. Creams were not always recorded on the Medicine Administration Record, and recording of the application of topical creams was not completed in line with prescribed instructions. People who used thickeners to aid swallowing did not have accurate care records to show how to use this medicine and when thickeners were used there was no accurate record of its use. The process for the management, administration and oversight of all schedules of controlled drugs was not in line with legislation. This was not safe. The home did not have a robust audit process, the most recent audit provided was July 2024. The home had implemented a resident of the day audit system however September was the first month this had been completed.