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 the ways people’s medicines were managed.

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.

The provider did not always evidence a proactive and positive culture of safety. There had been some improvement in learning lessons to continually identify and embed good practice.

At our last assessment we found the registered manager did not have systems in place to maintain effective oversight of accidents and incidents. Whilst this had been addressed, some improvements were needed to make sure the system the registered manager used to oversee safety events was accurate. The registered manager was working with the appropriate person within the provider’s governance team to address this. Practice errors such as medication errors were addressed and learning identified but did not always result in change of practice.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Processes were in place to support safe admissions into the service. Staff worked with partner organisation health professionals based at the hospital and at the service, during the process. People told us the plan for their stay at the service was discussed with them on admission, so they knew what to expect. People’s discharge from the service was co-ordinated between in-service and community support teams.

Systems for analysing and reporting safety events needed to be more accurate. 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.

Systems used by the registered manager to analyse safety events and reporting of these events were not always accurate in the data displayed. The registered manager acknowledged this and was addressing the issue. Staff understood their responsibilities in relation to safeguarding and people told us they felt safe at the service.

We did not look at how the service worked within the Mental Capacity act because all the people using the service had capacity to make their own decisions about their care.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were completed but varied in quality. Some risk assessments lacked clarity and hadn’t always been linked to associated care plans and the summary care needs section of people’s care records. Although there was no evidence that people had been involved in the development of their assessments, staff adopted a holistic approach to risk management. For example, one person's falls risk assessment took account of other physical health conditions that could increase their risk of falling and provided staff with clear instructions on how to support the person safely and minimise this risk.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Action had been taken to address environmental safety issues previously identified and action was taken during the assessment to address signage within the service which could have been confusing to people. The registered manager assured us that potential issues with the call system were being addressed to make sure people were safe. Personal Emergency Evacuation Plans (PEEPs) were in place, up to date and could be easily accessed in an emergency. Maintenance and other safety checks were in place.

The provider made sure there were enough staff to meet people’s needs. However, staff practice errors did not always support the safe delivery of care.

A recent multi-disciplinary meeting held to discuss medicines errors highlighted a significant workload associated with managing medicines. This needed to be addressed to make sure staff had the time they needed to dedicate to ensuring a safe system for managing medicines.

During the assessment, we discussed how deployment of staff could be improved, and we saw this put into practice. For example, on the first day of the assessment, there was no staff presence in the dining room which meant staff would have been unaware of an issue observed by the inspection team. On subsequent days staff joined people at the table supporting people and enabling conversation between people which resulted in a much more pleasant experience for people.

Staff were recruited safely and were happy with the training and support they received. Although training compliance was low in some areas this was being addressed.

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.

Standards of hygiene were well maintained. Appropriate procedures were in place to manage infection, and staff knew how to follow them.

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

There had been some improvements in the safe management of medicines since the last inspection which included safer storage arrangements and improved record keeping. However, these improvements on their own failed to ensure that medicines were managed safely.

People still did not always have their medicines administered safely or at the right times. We saw two people could not have their prescribed pain relief medicine for a short period because the stock had not been ordered in a timely manner. Other people did not have their medicines, creams and patches safely because the prescribers’ and/or the manufacturers’ directions were not followed properly.

When the prescriber made changes to people’s medicines there were communication and documentation failures within the service and between the service and external healthcare professionals. This resulted in people not always being given their medicines safely

When people were prescribed medicines to be taken ‘when required’ or with a choice of dose, the protocols to support their administration were still not detailed enough to ensure they were administered safely and consistently. When people were given doses of their ‘when required’ medicines staff failed to record if the medicines had been effective.

There was a system in place to identify and monitor medicine’s errors. However, the number of errors identified and the recurring themes of omissions, missed and incorrect doses, interruptions during medication rounds, and the increased complexity of medication management within the service indicated that the existing systems and processes had not yet been fully effective in preventing medication errors and ensuring medicines were managed safely

After the inspection and feedback with the nominated individual, the provider investigated concerns highlighted and a clear and well considered action plan was provided. This helped mitigate the seriousness of the concerns and provided assurances that the safe management of medicines could be achieved. However improvements take time to embed and sustain, and the effectiveness of the action plan will be tested at a future inspection.

We found no evidence that people were harmed at the time of the assessment because the harm is not always immediate. However, people were placed at increased risk of harm by not managing medicines safely.