Inglefield Nursing & 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 remained good. This meant people were safe and protected from avoidable harm.

People told us they felt safe and staff understood safeguarding processes and how to raise concerns. However, the service was in breach of legal regulation in relation to safe care and treatment. Risk management systems were not consistently effective, the environment was not always safe, and medicines were not always managed in line with best practice. These shortfalls reduced assurance that risks were consistently identified, monitored, and mitigated.

This service scored 63 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive learning culture that supported continual improvement in safety. Systems were in place to record and review accidents and incidents, but these did not consistently ensure that learning was identified, acted upon, and embedded into practice to reduce the risk of recurrence.

Managers reviewed and signed off accident and incident records without clearly documenting actions taken, measures implemented or outcomes achieved. As a result, where people experienced repeated incidents, such as multiple falls, it was not always clear that risks had been effectively reviewed or that targeted actions had been taken to reduce the likelihood of similar incidents occurring again.

Although the provider completed monthly analysis of accidents and incidents, resulting prevention action plans were generic and did not demonstrate how learning from individual incidents had informed improvements in care or service delivery. This limited the service’s ability to demonstrate that trends, themes, or contributory factors had been meaningfully addressed, increasing the risk that similar incidents could continue to occur without effective preventative measures in place.

Despite these shortfalls, staff understood how to report accidents and incidents and told us these were investigated promptly. People using the service said they felt safe and supported when accidents occurred. Relatives reported that staff communicated openly, acted honestly when things went wrong, and investigated incidents thoroughly.

The registered manager acknowledged that systems for learning from incidents were not always effective and recognised the need for improvement. At the time of the inspection, the management team had started to develop a more robust approach to reviewing incidents and strengthening follow-up actions.

The provider had effective systems in place to support safe pathways and transitions of care. Staff worked with people and healthcare partners to understand what being safe meant to individuals and how best to achieve this, while protecting people’s rights to live free from abuse, discrimination, avoidable harm, and neglect.

Staff considered people’s needs, risks, and preferences and ensured the service could meet needs safely. Pre-admission assessments were detailed, robust, and person centred, supporting safe decision-making before admission. People and their families told us they received clear information about the service and what to expect, which reduced anxiety and supported smoother transitions.

The service demonstrated a flexible and personalised approach to transition planning. For example, staff supported a person who was reluctant to leave their home by inviting them to visit the service informally for a cup of tea rather than completing a formal assessment in their home. This reduced distress and supported a phased transition that respected the person’s emotional needs.

Systems supported safe and coordinated transfers with external professionals. Staff shared concerns appropriately and promptly, supporting continuity and safety when people moved into, between, and out of the service. Handovers included relevant and up-to-date information about new admissions, including medical history, identified risks, and current care needs. As a result, people experienced safe, well-coordinated transitions that reduced risk and promoted continuity of care.

The provider worked with people and healthcare partners to understand what being safe meant to each individual and how best to achieve this. Staff focused on improving people’s lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

Staff and managers demonstrated a strong understanding of safeguarding responsibilities. Staff could access the provider’s safeguarding policy and procedure, and they completed safeguarding training during induction and annually thereafter.

Staff and managers demonstrated a strong understanding of safeguarding responsibilities. Staff had access to safeguarding policies and completed safeguarding training during induction and annually thereafter. Effective systems supported practice, including safeguarding information displayed throughout the service, regular safeguarding meetings, oversight from a designated safeguarding champion who completed quarterly reports to highlight concerns and areas for improvement, and timely referrals to relevant authorities, with incidents discussed with people to ensure appropriate responses.

Oversight systems promoted learning and lawful practice. The service maintained a safeguarding tracker to record, monitor, and evidence the outcomes of referrals, and lessons learned from investigations were shared with staff to improve practice. Staff submitted applications to lawfully deprive people of their liberty when required and received training on the Mental Capacity Act, ensuring practice remained lawful and safe.

The provider did not always ensure risk assessments were fully personalised or clearly linked to risk mitigation. Staff completed risk assessments for all people; however, many were standardised tick-box documents and did not clearly guide care or reflect individual risks.

Risk assessments focused on generating numerical scores rather than identifying personalised actions. Documentation did not consistently show how identified risks informed tailored interventions or changes to care delivery. This reduced assurance that risks were proactively reviewed and mitigated in partnership with people.

Despite these recording shortfalls, staff demonstrated a good understanding of people’s risks in practice. Staff knew people well, understood their individual needs, preferences, and mobility needs, and responded appropriately to changes in people’s condition to manage risk on a day-to-day basis. For example, 1 person experienced a reduction in the number of falls they suffered. However, assessment and care planning documentation did not always evidence the steps staff took to reduce risks or put preventative measures in place. This meant there was not always evidence of a coordinated and clear plan in place to support people.

The provider recognised the need to improve the quality and individualisation of risk assessments. During the inspection, managers began reviewing and updating assessments to strengthen links between identified risks, care planning, and mitigation. These processes were not yet fully embedded across the service.

The provider did not always identify, assess, and control risks within the care environment. Staff implemented systems to maintain the safety of the premises; however, these did not consistently ensure that equipment, facilities, and environmental arrangements supported the delivery of safe care.

Environmental risks were identified during the inspection that had not been adequately managed. Hot water pipes were uncovered, which increased the risk of scalding to people. Access codes to locked sluice rooms were written on doors, reducing the effectiveness of access controls and increasing the risk of unauthorised access.

Fire safety arrangements required improvement to ensure staff were prepared to respond safely in an emergency. Simulated fire drills had not been completed, limiting assurance that staff were familiar with emergency procedures. Evacuation sledges were available to support people with limited mobility; however, not all staff had received training in their use, which increased the risk that equipment would not be used safely or effectively.

Despite these shortfalls, several environmental safety measures were effective. The building was secure, windows were appropriately restricted, and external waste was stored safely. Waterborne infection risk controls were up to date, and equipment was regularly serviced and maintained. Sensors were appropriately positioned, furniture and fittings were securely fixed, and maintenance staff demonstrated a clear understanding of their responsibilities and responded promptly to concerns.

The management team took action to address risks identified during the inspection. Some hazards were resolved promptly, and plans were in place to strengthen fire safety arrangements, including scheduled fire safety training and improvements to access controls.

The provider ensured there were enough suitably qualified, skilled, and experienced staff to deliver safe care that met people’s individual needs. Staffing arrangements were planned to support effective teamwork and continuity of care. Recruitment practices were robust and helped protect people from harm.

Safe recruitment processes were followed consistently. Recruitment files showed Schedule 3 checks had been completed to an appropriate standard, demonstrating effective vetting of staff. The service had not used agency staff for over six months, which supported continuity and enabled staff to build consistent relationships with people.

Staffing levels were sufficient to meet people’s needs, despite limitations in the dependency tool used. Managers recognised that the tool did not fully reflect people’s care needs and acknowledged the need to introduce a more effective system to assure staffing levels in relation to people’s needs. People did not raise concerns about staffing levels. Staff told us they felt supported by managers and confident in their roles, and managers responded promptly when concerns were raised. Relatives also reported that staff were available and responsive.

Systems were in place to support staff competence and safe practice. Mandatory training was up to date and aligned with people’s needs and risks. Staff received regular supervision, competency assessments, and appraisals in line with the provider’s policies and procedures, supporting them to maintain the knowledge and skills required to carry out their roles safely and effectively.

The provider assessed and managed the risk of infection effectively. Staff implemented systems to detect and control the spread of infection, and concerns were shared promptly with appropriate agencies. Leadership oversight and staff training supported consistently high standards of infection prevention and control.

The provider’s policies and procedures supported good infection prevention practice. The service was clean, well maintained, and free from unpleasant odours. Handwashing posters were displayed at communal sinks and in bathrooms, and cleaning schedules were in place with spot checks to monitor standards. Laundry and kitchen areas were managed safely, reducing the risk of cross-contamination.

Staff demonstrated a strong understanding of infection prevention and control procedures. They had completed current training and understood the correct use of personal protective equipment (PPE) and the actions required in the event of an outbreak. Staff competencies in donning and doffing PPE were regularly assessed, supporting safe practice and reducing the risk of infection transmission.

Oversight systems helped maintain safe and consistent practice. PPE was readily available and used correctly, and staff followed safe care routines to minimise infection risks. Regular audits, supervision, and training supported sustained standards. People experienced a clean and safe environment, and 1 person said, “It always smells clean here.”

The provider did not always ensure medicines were stored, managed, and administered in a way that consistently met people’s needs, capacities, and preferences. Staff implemented systems to support medicines management; however, these did not always ensure safe storage or fully personalised guidance.

Medicines storage arrangements did not consistently meet required standards. Fridge temperature records did not provide assurance that medicines requiring refrigeration were always stored within the correct temperature range. Three liquid medicines were still in use despite being past their in-use expiry date, and 1 medicine was stored in the fridge contrary to the manufacturer’s instructions. These issues reduced assurance that medicines were always safe and effective.

Care plans and ‘as required’ (PRN) protocols were not consistently individualised or sufficiently detailed. Some guidance did not clearly describe how medical conditions should be managed where multiple medicines were prescribed for the same condition. This limited assurance that people would receive medicines in a way that fully reflected their individual needs.

Despite these shortfalls, medicines administration was generally consistent and timely. Staff recorded and accessed people’s known allergies and preferences for taking medicines. Covert administration followed best interest decisions, with appropriate involvement of professionals, families, and advocates where required. Risk assessments supported safe self-administration, and staff demonstrated a good understanding of the electronic medicines system in use.

Managers recognised the need to improve medicines storage and personalised guidance. Plans were in place to review PRN protocols, ensure adherence to manufacturer instructions, and strengthen temperature monitoring.