Ingleby Care Home

On this page

• 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

The service was not well-led and has been rated inadequate. We found a breach of regulation relating to governance and oversight. There had been no registered manager since 01 December 2024. There had been several changes to management during that time and the provider had failed to ensure robust quality assurance and oversight of the home. Staff had not been appropriately supported through the changes by way of support meetings and time meetings were management focused. A staff survey had been conducted however we were told the results could not be found. Audits were completed however the quality was inconsistent, staff had not always been given responsibility for driving improvement and learning. Action plans were not always in place and were not always reviewed. A home improvement plan was in place, however our assessment found widespread areas for improvement which had not been identified by the provider meaning there was a failure to learn and improve the quality of the service people received.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us the current management team were approachable and commented that if they raised concerns or made suggestions they would be listened to. The regional manager told us morale within the team was a lot better than it was as there was now some continuity in the management team with a new deputy and support from the current manager. A permanent home manager was due to start in the near future and the current home manager would support with their induction and be their work buddy. The direction and culture of the home was impacted by the inconsistency in management and leadership over the past year. There was no formal strategy in place to develop and embed a shared culture.

There were inconsistencies in staff support. Staff had not received one to one meetings throughout the year to support them through changes in leadership and management. Staff meetings were not co-produced, and minutes indicated they were management led with no clear focus on involving staff and valuing their contribution. A staff survey had been completed, and a provider report from June 2024 stated results were being analysed however we were told these, “Could not be found” meaning the provider had missed the opportunity to hear staff feedback and include them in developing a shared direction and culture.

Staff commented on the various changes in management. Some staff said they were positive about the current leadership team, and said they felt listened to and supported. Leaders acknowledged the impact of management changes, acknowledging that there had not been consistent home management, a longstanding regional manager had recently moved on, and a new home manager would be in post towards the end of October 2024. The current senior home manager leading the home commented they hoped to be involved in supporting the incoming manager. This was confirmed by the incoming regional manager confirmed they would continue to be involved with the home.

The organisation’s senior leadership team were a consistent team of staff. However, insufficient oversight and governance had affected the overall quality and standards at the home. There was limited evidence of the provider supporting staff and valuing feedback provided. Staff and resident surveys had been completed; however, the manager of the home was unable to provide any results or learning from the feedback. Staff meetings were held, however, there was limited evidence of co-production. Changes in leadership meant oversight was not robust, and quality assurance mechanisms had been implemented with differing degrees of thoroughness meaning they had not always been effective. Staff support and wellbeing had not been consistently provided by the organisation.

Staff said they felt able to raise any concerns and that they would be listened to, adding they knew they could escalate concerns to CQC if needed. The manager confirmed there was no documentation available in relation to surveys, even though it was referenced in an audit that they were being analysed.

A whistleblowing policy was in place and there was a secure email address which staff could use to raise any concerns. This could be done anonymously. A provider oversight report from June 2024 stated staff surveys had been completed and were in the process of being analysed. At the time of the assessment the manager of the home was unable to find any surveys or results meaning staff feedback had been lost.

The senior home manager said they had a diverse workforce. The incoming regional manager said protected time for prayers would be facilitated in the home if needed. Cultural events and festivities were not acknowledged or celebrated within the home. It was acknowledged this was an area for improvement.

Staff had attended training in equality and diversity and an Equal Opportunities Policy was in place. However, processes to raise awareness of and celebrate cultural events such as black history month were not in place. The regional manager explained some work had taken place in sister homes to understand the needs of veterans so homes could become veteran friendly. They said, “Cultural festivals and celebrations is something we need to get better at.”

The management team explained there were a range of audits completed by the deputy manager, home manager and senior carers which were verified by the regional manager during visits to the home. This process had not been effectively implemented to drive improvements at Ingleby Care Home. The senior home manager indicated this was due to inconsistencies in home management. However, the provider did have a stable and consistent senior leadership team, including a quality team. During the assessment there was a change in regional management. The incoming regional manager said, “Action plans should be generated for all audits.” They shared a new process they planned to implement to ensure increased oversight of audits so progress on completing actions could be monitored and reviewed weekly.

There had been no registered manager since December 2023. Since then, there had been several changes in management which had resulted in inconsistent leadership and oversight. At the time of the assessment a senior home manager was overseeing the home, alongside regional management support. A deputy manager had been in post for a few weeks and a new home manager was due to start towards the end of October 2024. A range of audits and provider visits were taking place, and some areas for improvement had been identified. However, there was not always a clear line of accountability for the completion of actions, action plans were not always in place and where they were, they were not routinely reviewed, or signed off as completed. Some areas of improvement, such as audits being more detailed and robust had been an action since at least May 2024 with no evidence of improvements. Concerns identified during the assessment, had not always been identified by the provider, and where they had been sustained improvement was not always evident

The provider was engaged with partnership working. This needed to be developed and embedded to ensure learning and improvements could be sustained so people received consistent, high-quality care.

Some staff commented on the need for a strong management team who held regular meetings to discuss issues and training. Other staff member said they felt able to approach the leaders of the home and felt they were listened to depending on the issue raised.

There was mixed feedback from partners, with some providing positive feedback on partnership working in relation to ensuring peoples’ healthcare needs were met. However, others noted that recent engagement with provider forums, for example, had reduced.

Staff worked in partnership with healthcare professionals. Some people were also supported with community engagement however this was not everyone’s experience. Staff meetings were held however there was limited evidence of partnership working with staff to engage them in improvements. The provider was engaged in the Responding to and Addressing Serious Concerns process with the local authority safeguarding and commissioning teams.

The senior home manager and regional manager said there were a range of methods to ensure learning and improvement. This included provider bulletins, monthly meetings where learning was discussed and a policy focus of the month. Widespread areas for improvement were identified during the assessment, which the senior home manager and incoming regional manager acknowledged and did not disagree with. The incoming regional manager discussed initiatives they hoped to introduce to develop and improve the service in relation to oversight, diversity and activities, but these had not yet been implemented.

Audits had not been effectively implemented or monitored to ensure learning and improvement. There was a lack of provider oversight in ensuring actions were progressed. A home improvement plan was in place, however some individual audits also generated action plans and areas for improvement which were not triangulated and recorded on the home improvement plan. The provider failed to ensure named individuals were responsible for taking improvements forward and progressing actions. There was a failure to ensure a robust focus on learning and improvement was in place.