Ings Grove House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement although the service is no longer in breach of regulation. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Information about the service was shared with staff through various updates and meetings. Staff knew about the vision and values of the service, they told us there were posters about the service explaining them. Staff felt the culture within the service was good, they told us, “Everybody has decency and intellect to try and respect even if you don’t agree. I feel comfortable and happy” and “The culture is friendly.”

Leaders did not always demonstrate the necessary skills, knowledge and experience to lead effectively.

Although some improvements had been made, the registered manager did not always demonstrate a robust oversite of the service. For example, oversite of some care charts, issues in relation to maintaining effective oversight of accidents and incidents and issues with incorrect signage around the service had not been fully addressed. We also noted that an action log, within the provider’s overall implementation plan, in relation to people being given a copy of their care plan within one week of admission; had not been actioned despite the action being marked as completed and embedded in the implementation plan over 6 months prior to our assessment.

The registered manager also needed to demonstrate a strong leadership role in managing the relationship in terms of roles and responsibilities with the community healthcare team based at the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People’s views were encouraged and action taken to address any issues. Although staff felt listened to, there were no formal systems in place to gain staff feedback.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed a diverse staff team including different ethnic backgrounds and genders. Staff felt involved in the service through staff meetings and felt their opinions were listened to. Outcomes of incidents, complaints, safeguarding events and assessments of the service were shared with staff to support their understanding of what was happening in the service.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

A new Head of Service had been appointed since the previous assessment and had implemented several measures to improve governance, quality assurance, and operational oversight. While these initiatives had contributed to improvements within the service, they were still in the early stages of implementation. More time was needed to demonstrate that they were fully embedded and effective in ensuring governance issues, especially those relating to the safe management of medicines, were consistently identified and resolved.

The provider did not always work in partnership, so services worked seamlessly for people.

Although some improvements had been made in establishing an effective and productive relationship with partners, this had not been sufficiently robust to prevent issues that could have impacted on people’s health and wellbeing.

The provider had not fully embedded systems for continuous learning, innovation and improvement across the organisation and local system.

The provider had taken learning from the outcome of our previous assessment of the service and although had been pro-active in producing an action plan to demonstrate this, further work was needed to demonstrate that lessons had been learned that would drive sustained improvement within the service. This was particularly relevant in issues around safe management of medicines.

The management team were responsive to the assessment and demonstrated a commitment to continuous improvement.