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 requires improvement. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment and safeguarding service users from abuse and improper treatment.

This service scored 28 (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 learnt to continually identify and embed good practice.

There were no effective systems in place to ensure lessons could be continually learnt.Improvements made to the service were not always effective or sustained. Since our last inspection the provider had introduced a lesson learnt folder. A lessons learnt document had also been completed for some incidents. However, when changes or incidents occurred, it was not always clear what action was taken.As reported on in ‘involving people to manage risk’, when an incident occurred in relation to choking, the care plans and risk assessment in place had not considered this risk and we saw people did not always receive safe diets to manage this risk. This meant the home had failed to act on the incident and review this to reduce the risk of recurrence.

We found concerns continued to occur as the systems in place to monitor these were not effective. For example, some radiator covers were loose, damaged and exposed. We identified this at our last inspection, and the provider initially took action to resolve this. However, the systems in place to consistently monitor the safety and suitability of these radiator covers were not effective as the local authority told us and reported to the provider they had found the same concerns with damaged covers again when they visited the home in February 2026. We also found the same concerns at this inspection.

The provider did not always ensure, establish and maintain safe systems of care.

The provider told us they had systems in place to ensure people’s needs were assessed before they started using the service. We did not see any evidence of these assessments as part of our inspection as these were not contained in the care records we viewed or shared with us.

We found people did not always have detailed or up to date care plans or risk assessments in place. For example, a person’s mobility needs had significantly changed and the information in place did not reflect this. This placed people at risk of receiving unsafe and/or unsuitable care.

People were not always protected from potential abuse in a timely way.

The provider told us there was a system in place to ensure safeguarding referrals were made when needed. However, an incident had been documented, and we found it had taken the provider a further 8 days to make the required safeguarding referral. There was no evidence to show any action had been taken during this time to mitigate the risk of repetition or additional harm.

During our site visit we identified and shared 3 safeguarding concerns with the provider. The provider did not take any action to alert the local authority safeguarding team to these concerns. Therefore, following our inspection, we made the required safeguarding referrals to the local authority safeguarding team. In addition, the local authority told us they had also raised a safeguarding referral themselves about a different concern following a quality monitoring visit after identifying the provider had not raised a safeguarding referral as required.

However, the training matrix confirmed most staff had received up to date safeguarding training and staff were able to recognise potential abuse.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In [care homes/hospitals], this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that when needed, DoLS were in place for people.

People and relatives raised no concerns around safety. One relative told us, “The staff treat her brilliantly. She’s much safer here it’s better than at home”.

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.

At our last inspection we found concerns with the management of risk and told the provider to take action. At this inspection we found the necessary improvements to keep people safe had not been made.

When people had been identified at risk of choking, the provider had not taken action to keep them safe. Two people had been identified at risk of choking; the GP had made referrals to Speech and Language Therapists (SaLT) for support with this. There was no detailed care plans or risk assessments in place that identified what was safe for these people to eat whilst these referrals were being considered. For 1 of the people, the GP had made recommendations with regards to their diet. However the care plan and risk assessment did not reflect this, and we saw the person was not eating a diet in line with the GP’s advice. This placed this person at further risk of choking and harm. The second person’s care plan stated they needed a soft diet. We saw they were receiving a diet that was not line with this which placed them at risk of choking and harm. We had to intervene to stop the person from eating the unsuitable food they had been given.

Care plans were not always consistent, up to date or in place. Some of the care plans we viewed lacked detail or were not accurate. For example, 1 person’s care plan had not been updated to accurately reflect they were currently supported in bed. There was no detail about the number of staff that were needed to safely support this person. The provider was using both paper and electronic documents for people and these contained conflicting information about peoples care needs, placing them at risk of receiving unsafe or unsuitable support.

Personal Emergency Evacuation Plans (PEEP’s) had not always been updated to reflect changes in people’s care. For example, 1 PEEP referred to the person transferring out of bed with the support of staff into a wheelchair, when it had now been identified they required a hoist and a specialist chair to sit in.

However, people raised no concerns with how their risks were managed. We found some examples of some appropriate risk assessments that were in place for people.

The provider did not always detect and control potential risks in the care environment. After our last site visit, we raised concerns about the safety of the environment and told the provider to take action. We found some of the actions had been taken, however further concerns were identified at this inspection.

We saw areas of the home that were unsafe and posed a risk to people, staff and members of the public. This included exposed radiators and pipes in communal areas that were hot to touch and exposed wires which posed a risk of entrapment.

There were no effective systems in place to ensure people’s environments were safe. The processes the provider told us they had in place to monitor the safety of the environment were not effective in identifying areas of improvement and they had not identified the concerns we found at this inspection.

However, people and relatives raised no concerns about the environment.

The provider did not always make sure there were enough staff available to support people.

The dependency tool the provider had in place to calculate the number of staff required in the home was ineffective as it was inaccurately completed. The tool had not considered people’s up to date needs and did not reflect the correct care they received. For example, 1 person had a score that showed they required only prompts with their medicines, when staff were responsible for administering medicines to this person. Another person’s score did not reflect the correct levels of support they needed with their personal care and mobility. This meant the provider had failed to correctly reflect people’s needs when using the dependency tool to ensure there were enough staff available to support.

We saw that staff were not always deployed effectively to keep people safe and meet their needs. For example, the staff member responsible for administering medicines during our site visit was repeatedly called away to support other people whilst administering medicines. This increased the risk of medicines errors occurring.

However, we saw people received support from staff when they requested it and they did not have to wait for support. People and relatives raised no concerns about the staffing levels in the home. One person said, “I get on well with the staff, there seems enough of them”. We received mixed views from staff on if there were enough of them.

There was no effective oversight of training to ensure staff were suitably skilled to provide safe and effective care. We were unable to establish during our site visit if staff were trained in medicines administration as the training matrix was not up to date and the provider was unable to tell us the requirements needed. After our site visit, we received confirmation staff were adequately trained in all areas. The training matrix showed us that most staff had completed the required mandatory training.

Staff had received the relevant pre-employment checks before they could start working with people to ensure they were safe to do so. However, there was no system in place that demonstrated this, we viewed staff files and information was not always available for us to review and had to be sourced from other areas.

The provider did not always assess or manage the risk of infection.

We saw areas of the home that posed as an infection control risk. This included a lid of a toilet in the communal bathroom used by people that was broken and taped together; there were also loose tiles in the same bathroom. We also observed there were face masks with expired usable dates located in the upstairs corridor. This all placed people, staff and visitors at risk of potential harm and infection.

The systems and audits the provider told us they had in place to monitor IPC, which included monitoring PPE and a laundry audit, had not identified the concerns we found and therefore were not effective.

The provider did not always make sure that medicines were safely administered, disposed of or stored safely.

We found concerns with the how medicines were managed. One person was using a paper medicines administration record. (MAR) There were no dates on this MAR to show when these medicines had been administered. This meant we had no assurance that this medicine had been administered as prescribed and placed this person at risk of not receiving these medicines when needed.

Another person was prescribed a patch to be changed and administered every 24 hours. Staff told us this was to be administered to a specific part of their body. There was no guidance in place that showed this, or detailed where this patch should be administered or the reasons for this. This placed this person at risk of having this patch administered in the incorrect place or having their patch administered in an inconsistent and unsafe manner.

Staff told us they used a homely remedies system for administering Paracetamol as pain relief to some people when required. Staff told us they could not always administer these medicines to these people because there were no medicines administration records in place. After our inspection the provider sent us a copy of the homely remedies policy and a homely remedies administering sheet to show people had received these medicines when needed. This raised concerns as the staff member administering medicines on the day of our inspection, was unaware these were in place. This meant people may be at risk of not receiving pain relief if needed.

In addition, we reviewed the policy the provider sent to us. We found the provider had not always followed their own policy for the administration of these medicines. For example, the policy stated the provider would list the name of the product, what it could be used to treat, the dose, the frequency of the dosing and the maximum daily does. We did not find any evidence to demonstrate this was always completed.

During our site visit, we were unable to establish if staff were trained or competent in medicines administration as the training matrix was not up to date and we were not provided with any competency checks. The provider sent us assurances around medicines training after our site visit.

However, people raised no concerns with how their medicines were managed. One person told us, “They give me my medication, it’s what I need.” Other people received their medicines as prescribed. We found ‘as required guidance’ was in place and stock checks were accurate.