Ings Grove House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. The last time this key question was assessed it was rated good. At this assessment the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent. The service was in continued breach of legal regulation in relation to good governance.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always accurately assess people’s needs and make sure their care and treatment was effective.

Gaps and inaccuracies in people’s records meant that risk assessments and care plans were not always reflective of people’s current needs. Timely reviews of assessed needs were not always taking place. For example, 1 person had 18 care needs that were 7 days overdue for review.

There was an admissions process in place which included completing an “about me” document. This included discussing aspects of health, wellbeing and communication needs with the person.

The provider did not always plan and deliver people’s care and treatment with them. They did not always follow legislation and current evidence-based good practice and standards.

We found examples when the service had failed to adhere to best practice guidance and therefore standards of care fell below what was expected. For example, there were 9 people who had been assessed as requiring fluid monitoring and placed on “fluid watch.” This meant they were at high risk of dehydration. Records demonstrated each person had accepted fluids below their identified target, daily and over time. In addition, 1 person was below their fluid target of 1500mls on 6 out of 7 days, on 1 day only having accepted 490mls of fluids. There was no action taken to address this. The provider had failed to effectively monitor this and mitigate the risk of dehydration to people.

Records showed some nationally recognised assessment tools were in use to assess people’s needs and risks. However, they were not always being used correctly as at times they contained inaccurate information.

People gave positive feedback about the food. Comments included, “The food is lovely,” “The meals are good” and “The food is alright not bad at all, and you get enough.”

The provider did not always work consistently well across teams and services to effectively support people.

People had access to health professionals, provided by a partner agency who were based at the service. Staff worked with these health professionals to support people. However, the health care professionals used their own IT systems for people’s records, and not all care staff were able to access it. In addition, clinical information was not consistently recorded on the provider’s IT system. Clinical oversight relied heavily on the partner organisation. The provider had no effective mechanisms in place to consistently and robustly ensure clinical information was recorded, shared and used to manage people’s safety.

We observed some examples of care staff working together as a team to meet people’s needs.

The provider supported people to maximise their independence. Staff supported people to reduce their future needs for care and support. However, people’s health needs were not always robustly monitored and met to support their wellbeing.

People had access to resources and health professionals to support improvements to their health and maximise their independence. For example, physiotherapy. People gave positive feedback regarding this. Most people lived at the service short term, until they physically improved and were able to manage with less support. However, improvements were needed with regards to oversight and monitoring of people’s physical health.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met clinical expectations and the expectations of people themselves.

Systems and processes were ineffective in ensuring robust oversight and monitoring of people’s health. For example, monitoring of people’s bowel health. We found people were going for prolonged periods of time without opening their bowels. For example, 1 person’s charts recorded that no bowel movements had occurred for 13 days indicating they were very constipated. The person was prescribed medication to treat this. However, the medication was not administered for 24 days, and it was documented as ‘refused’ or ‘not required’. There were no records to show this had been reported to the clinical team. Lack of effective monitoring and failure to administer the medication meant the person experienced constipation, placing them at risk of harm and discomfort. In addition, monitoring of people’s fluid intake was not effective in mitigating risks to those who were consuming low fluid amounts.

The provider told people about their rights around consent and respected these when delivering care and treatment.

The service was working within the legal framework of the Mental Capacity Act (MCA). Staff sought consent from people prior to providing support.