Archived: Inglewood Residential 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to people’s safe care and treatment and medicine administration.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice.The providers systems to review accidents and incidents and apply learning were not always effective. Staff understood the actions to take when incidents occurred. We saw when incidences had occurred, staff took immediate actions and documented these in the system. However, there was no review of relevant risk assessments and care plans. For example, one person had experienced recent falls no review of their falls risk assessment or care plan had taken place this meant the person remained at risk of further falls. The provider told us there was a system in place which identified possible themes and trends however, the provider was not reviewing this information and taking any action. This meant the provider did not have a suitable system in place to learn lessons from incidents and make changes to avoid these happening again.

The provider worked with people and healthcare partners. However, when healthcare advise was given this was not always reflected in the person’s care records. This put the person at risk of not having their care needs met in a safe way. The registered manager told us assessments and questionnaires were undertaken with people to ensure their independence was prioritised. The provider had systems in place to assess people’s needs and develop care plans, but these were not always effective. We saw one person’s needs had changed; however, the care plan had not been updated despite being reviewed. This meant the system in place was not always effective in ensuring accurate information was available to staff. People and their relatives told us they were involved in assessments and care plans. A person told us, “My [person’s name] came in for an assessment and we didn’t know what to expect, but they has been supported very well.” Staff told us people had their needs assessed and care plans were put on to an electronic system when they began using the service.

The provider worked with people and healthcare partners to safeguard people from abuse. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. People told us they felt safe at Inglewood Residential Home. A person told us,” I have no concerns but if I did, I would definitely talk to the staff. I feel safe.” Leaders and staff understood safeguarding procedures and understood how to recognise the signs of abuse. They were aware how to report any concerns and had received relevant training pertaining to this. A staff member told us, “We have training in safeguarding and can raise concerns with the manager or outside if needed.” Incidents were recognised and referred to safeguarding teams. Investigations were carried out and information shared with the Local Authority. Applications were made to the authorising body for a Deprivation of Liberty Safeguard where required and any conditions required were met.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People told us they were supported to maintain their safety. Staff understood risks to people’s safety and were able to describe the actions they took to keep people safe. However, the registered manager told us risk assessments were in place and reviewed monthly, but these were not always effective to identify people’s needs where there was a change. We saw, where someone had fallen there was no review of the risk assessment and care plan to manage the risk of falls. Another person’s care plan did not reflect the recommendations made by Speech and Language Therapists (SALT) following a change to their diet. Furthermore, risk assessments had not been updated to consider this change. This placed this person at an increased risk of not receiving the correct support they needed with their diet. Staff had good knowledge of people’s risks, including the risks relating to SALT and falls and were working in ways to keep people safe. The provider informed us they will update the person’s risk assessments and care plans to reflect the modified diet. We will review this as part of our next inspection. Partners told us the provider was undertaking additional training to improve on care plans to identify risks.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.We saw other concerns which included a worn carpet, and a loose radiator cover in the communal area. We shared these with the registered manager who took immediate action to resolve this. We saw other areas of the home required decoration; however, the provider had agreed an improvement plan to address this with local commissioners. The provider’s systems did not always ensure the safety of the environment. For example, the fire risk assessment in place had not been reviewed since 2022. This meant we could not be assured the action in the risk assessment had been addressed. Since the inspection the provider has informed us the risk assessment review date has been arranged, we will review this as part of our next inspection.However, people told us they felt safe within their environment. A person told us, “The environment is safe, so I don’t have to worry about her walking down long corridors.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. People and their relatives told us there were enough staff to support them safely. A person told us, “The staff are pretty good, and they are always around.” We saw staff were available to support people when they needed it for example call bells were answered promptly. The registered manager told us they had a dependency tool in place. The provider’s system determined how many staff should be available. Staff were recruited safely. The provider had a recruitment policy in place. Some historic records showed gaps in information on application forms however, the provider was taking actions to address this. Staff told us they received training and an induction into their role. The registered manager told us there was a matrix in place which gave them oversight of the training staff had undertaken and when this was next due. Records showed staff had received training for example, in safeguarding, medicines administration and infection prevention control, however some staff training was overdue for completion of a refresher course.

The provider had a system in place for Infection prevention Control (IPC) with an up-to-date policy. People told us the home was clean and tidy. A person told us, “I know that there are no frills but on the whole, it is functional, clean.” Staff told us they had received training in IPC and we saw staff used the Personal Protective Equipment (PPE) available. The provider told us they had an external audit undertaken with actions recommended. We saw these had been actioned, for example, a new sluice had been created following IPC advice.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider’s systems to ensure people’s medicines were administered safely were not always effective. We checked the stock control systems in place and found records did not match the amount of stock available. This meant we could not be sure people had received their medicines as prescribed. The electronic medicines administration system (EMAR) showed some peoples medicines were administered late. We spoke to staff about this and they could not tell us why this had happened. This meant people were always not receiving their medicines at the times prescribed. Guidance was not consistently in place for staff. For example, where people had topical patch medicines there was no record of where this was administered to enable rotation in line with the prescriber’s guidance. Where people had ‘as required’ medicines, there was no guidance in place to ensure this was administered in line with how it was prescribed. This meant we could not be sure people were receiving their medicines as prescribed.