Ings Grove House

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 remained 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 continued breach of legal regulation in relation to medicines management and good governance.

This service scored 44 (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 have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Systems and processes in place were ineffective in ensuring shortfalls were identified, lessons learnt, and improvements made. The registered manager did not maintain effective oversight of accidents and incidents. They were not always robustly recorded and reported to the relevant agencies. For example, the local authority and CQC. Whilst some examples of learning were shared with staff during meetings this was not effective in ensuring continued learning and improvement, due to shortfalls in the quality assurance processes. Where practice errors had been identified, these were often repeated. For example, medicines errors.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Processes were in place to support admissions into the service. Staff worked with partner organisation health professionals who were based at the service, during the process. However, there were gaps in some people’s records which meant we could not be assured that all relevant information was consistently being used to support people’s safe transition into and out of the service. In addition, 1 person told us about a problem they had with staff not knowing about a particular aspect of their physical health when they had arrived at the service. They told us, “Moving here was not a smooth process.” The registered manager did not maintain robust oversight of the work being done in partnership with health professionals based at the service. Therefore, we could not be assured that information sharing was consistent and effective to support people’s safety.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Oversight of safeguarding concerns was insufficient. Records were inaccurate and safeguarding concerns had not always been identified or reported to the relevant authorities. For example, 1 person had obtained a serious injury. The incident had not been recorded on the safeguarding log. The registered manager told us that they had not reported the incident to safeguarding. They had not submitted a notification to CQC. It was not clear why it had not been done and meant the necessary actions had not been implemented to protect the person. Where concerns were raised during the assessment appropriate and timely action was not taken. Not all staff had received safeguarding training.

The provider did not always work well with people to understand and manage risks. Risks to people’s health and safety were not always robustly assessed monitored and mitigated.

People had risk assessments and care plans in place. However, information in people’s records was not always accurate, up to date and reflective of their needs. For example, 1 person’s falls risk assessment was inaccurate, and their mobility care plan did not include sufficient information about their mobility support needs. This meant staff lacked guidance to enable them to support the person safely. Records were not always updated following incidents. For example, 1 person had a fall, and this was not reflected in their care plan and risk assessment. The nature of the needs of people accessing intermediate care combined with the high turnover of admissions in and out of the service meant that the availability of accurate and up to date information was highly important to ensure people’s safety.

The provider did not always detect and control potential risks in the care environment. They did not always make sure the environment supported the delivery of safe care.

Several areas within the service had signs on the doors stating that they should be locked or that they were staff only areas. For example, a storeroom had a sign which documented, "Store staff only" which contained wheelchair footplates and various other items of equipment. In addition, there was a sluice which had a sign, “sluice staff only, please ensure the sluice door is kept locked at all times” and contained various cleaning products including effervescent chlorine. However, we found these areas to be open and accessible to people at various intervals throughout the first day of the assessment. This concern was shared with the registered manager. However, on day 2 of the assessment the sluice door was again found open and accessible to people. This meant the known risk had not been addressed by the provider.

There was no grab file in place containing peoples Personal Emergency Evacuation Plans (PEEPs) for staff, the fire warden or emergency services staff, that could be used in the event of a fire to ensure people could be safely evacuated. The PEEPs were held on the electronic care records system in people’s individual records, which would not be easily accessible in an emergency. This concern had not been identified by the provider and was raised by the assessment team on day 1. Following this feedback the provider took action to address this.

Maintenance and other safety checks were in place. For example, gas safety and equipment checks.

The provider made sure there were enough staff to meet people’s needs. Staff participated in supervision sessions. However, the provider did not ensure staff were always trained to support the safe delivery of care.

There were enough staff at the service. Rotas were completed, and staff were allocated to one of 4 units in the service. We observed staff responding to people’s needs. Where there were any delays in doing so staff communicated with the person and apologised. People mostly told us staff responded to them without delay. However, 1 person said they waited for staff to attend to them. Feedback included, “There are enough staff. When I call them, they take about 10 minutes,” “You don’t have to wait long for them to come” and “Sometimes especially in the evening they take a long time to come up to three quarters of an hour.”

Staff did not always complete training modules identified as mandatory by the provider and some modules reflected low compliance. We found concerns in some areas where training compliance was low. For example, nutrition and hydration, and safeguarding.

Safe recruitment processes were in place.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean, and we observed domestic staff cleaning throughout the day. PPE was available for staff to use when needed.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

People did not always have their medicines administered safely or at the right times. There was a delay in obtaining newly prescribed medicines over the weekend, including antibiotics. This meant that some people experienced a delay of up to 4 days in starting their treatment or starting a newly prescribed dose of their existing medicine.

Some people were not given their medicines at the right times because the manufacturers’ directions were not followed. Other people missed doses of their medicines because their medicines were out of stock.

When people were prescribed medicines to be taken ‘when required’ the protocols to support their administration were not detailed enough to ensure they were administered safely and consistently. When medicines were prescribed with a choice of dose there was no information recorded to guide staff under what circumstances to administer the lower or higher doses.

The records of administration could not always be relied on because staff did not always observe people taking their medicine but signed records to confirm that the medicines had been taken. For example, we observed 1 person’s medicines left on their bedside table from morning to late afternoon, but the records were signed to confirm they had been given and taken. There were gaps on the medicines administration records when staff had not signed to confirm that a medicine had been given which meant the records were not accurate and could not evidence that medicines had been administered as prescribed. When the medicines administration records were not supplied by the pharmacy but were generated by the service there were no additional labelling directions recorded to guide staff how to administer medicines for example before or after food. This meant that medicines were not always given safely.

The records about creams were inconsistent. On some occasions the records showed that creams had been applied as prescribed but on other occasions staff failed to make a record of where the creams were applied. For 1 person the records provided evidence that the cream was not always applied to the correct area of the body.

Medicines were not stored safely. They were stored in a room where staff who were not authorised to access medicines could access the room because it was secured with a keypad lock and the code was not changed on a regular basis. Creams were not stored securely in people’s bedrooms and waste medicines were also not stored safely or in line with current guidance.

We found no evidence that people were harmed at the time of the assessment. However, people were placed at increased risk of harm due to unsafe medicines management.