Ingleside Residential Care 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 changed to requires improvement.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment and staffing.

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

The provider did not have systems in place to identify safety concerns. There was a lack of oversight and monitoring of lessons learnt.

The provider recorded falls but did not have other systems in place to record and monitor incidents and accidents. At the time of the inspection the service was not completing incident reports. This meant management were unable to review records to ensure corrective actions were taken resulting in changes to improve care for others.

Relatives told us they felt able to bring their concerns to the registered manager and felt they would be listened to.

Staff told us they knew how to raise concerns with the registered manager. A staff member said, “I have regular opportunities to raise concerns and share feedback with management.”

The service 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.

Staff told us people’s information and care needs were available on the electronic care planning system. Staff told us they felt confident to contact an external health and social care professional when required. A staff member said, “When concerns arise, we contact out-of-hours GP services, NHS 111, or emergency services. Healthcare professionals are involved in people’s care as needed to ensure their health and safety.”

A relative told us they were kept informed of any changes when their loved one was admitted to hospital.

Health and social care professionals were complimentary about working with the service.

Summaries of people’s needs were available in paper format in case of an emergency hospital admission.However, the information was out of date and not regularly reviewed. The risk around this was reduced as staff had access to the electronic care planning system which was regularly updated.

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 failed to ensure effective and robust processes and systems were in place to protect people from neglect and improper treatment. The provider did not have a system in place to monitor safeguarding concerns.

People were being deprived of their liberty without appropriate authorisation to do so. This meant restrictions were being imposed on people without the appropriate authority to do so. We raised our concerns with the local authority safeguarding team during the inspection.

Staff received training in safeguarding. We observed staff speaking kindly to people.

A relative told us, “[Person] has been in the care home now for years, I have always felt [person] is safe there.”

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider had not always ensured appropriate risk assessments were in place. For example, the provider had not completed an environmental risk assessment in relation to the accessible stairways. During the inspection we observed a person trying to walk upstairs with a zimmer frame. We had to intervene and find a staff member to support the person. This placed people at risk of avoidable harm.

Whilst risk assessments were in place in some areas, they were not sufficiently detailed, and 1 risk assessment did not have a person’s name on it. Risk assessments were hard to locate as they were in paper format in the registered manager’s locked office. This meant staff did not always have access to instructions on how to identify triggers to known risks or what action they should take to minimise risk. This placed people at increased risk of avoidable harm.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The service had a new fire detection system put in place just days prior to our inspection. On the first day of the inspection 1 external door leading to the garden was not alarmed or locked. The door led to an outside area where a gate leading to an alley was unlocked and accessible to all. The registered manager responded to our concerns and organised for the fire door to be made safe and contacted professionals for advice on how to secure the outside gate.

People had 2 different Personal Emergency Evacuation Plans(PEEP) documents in place, stored in different locations which were not always easily accessible. There was inconsistent information recorded on these documents on how to support people in case of a fire. The information available to emergency services was out of date, so they would not know who was in the building in the event of a fire. This meant that critical information on the evacuation needs of each person in the event of an emergency was hard to find and at times incorrect.

The provider responded to our concerns and ordered new fire evacuation equipment and started to review PEEP documentation.

The provider had a health and safety audit in place. However, this was ineffective and completed incorrectly. The audit failed to identify the lack of risk assessments and other shortfalls found during this inspection.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staff consistently told us they felt there were not enough of them working at the service. Comments included, “I believe people are looked after and they are our main concern, but I do think sometimes we need that extra staff member as sometimes it is really busy and we can’t spend much time with the clients”, “When assisting a resident that needs 2 carers to help them that leaves no extra carer for the home to help support our other residents”, “At times, I feel staffing levels are limited, with only 2 members of staff on shift. When both staff are required to deliver personal care, this can make it difficult to keep an eye on other residents, particularly those who may require supervision or reassurance. “Staff do their best to prioritise care, but additional staff would help ensure everyone’s needs are consistently met and monitored” and “There isn't enough staff, while doing personal care the 2 staff members on shift are too busy to watch the other residents.”

People and relatives told us they felt the staff were always busy and there were not enough of them on duty. A person said, “I try to talk to staff but they just have to go and do other things.” A relative told us, “I think staff work extremely hard. I do think they need a few more staff, for staff sanity and wellbeing the staff need more support. With what I have seen they manage well. I visit [person], and I think if the staff can get more support, it will be helpful.”

The service employed 2 staff members on each shift. However, we found 5 people required care to be provided in bed by 2 staff members and 3 people required 1 on 1 support with eating. Both staff members were required to administer medicines 3 times a day. The registered manager told us it takes approximately 30 minutes to complete medicines administration. This meant whilst staff were working to provide care to people who were in bed, supported people with eating or were administering medicines, other people at the service were not being supported or monitored at those times.

We observed people were left alone in the living room with no staff interaction and nothing to do.

The service had a system in place to determine the number of staff required in relation to people’s needs. However, the document was completed incorrectly and identified more hours required per shift than the service supplied. The registered manager responded to our concerns and started a review of the system and information on people’s needs.

Recruitment processes in place were not always followed. This resulted in some staff being employed into the service without having all the required pre-employment checks in line with the statutory requirements. We found some staff’s employment histories were incomplete, some staff did not have recorded interview notes, and not all staff had references in place. The registered manager was informed of our findings and told us they will complete a review of recruitment files.

The service did not always assess or manage the risk of infection.

The infection prevention and control audit in place was ineffective and completed irregularly. For example, temperatures in the fridges in the kitchen were not monitored and there were no thermometers in place to do so. However, the audit completed indicated the temperature was checked and appeared correct.

The service did not have appropriate systems in place to ensure soiled laundry was stored safely until it was washed. We discussed this with the registered manager who told us they would purchase appropriate equipment. We will check this at our next inspection.

The service appeared mostly clean during our inspection, however we found cobwebs in some people’s bedrooms and communal areas.

A relative told us, “[The service] always appears clean.”

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We could not be assured there was safe management of medicines. This placed people at avoidable risk of harm.

The audit to ensure safe management of medicine was ineffective and completed incorrectly. The audit stated there were enough medicines for all people, however we found 1 person had not received their medicine for 5 days. The registered manager contacted a medical professional to confirm the person was not harmed by this. We raised our concerns with the local authority safeguarding team during the inspection.

During the inspection we found 1 person did not receive 1 of their morning medicines, because staff could not find it. When staff found the medicine later in the day, it was not administered to the person. This was brought to the attention of the registered manager who contacted a healthcare professional for advice about whether it was safe to administer this medicine later than prescribed.

The provider did not follow their medicine policy. Where people were prescribed ‘as required’ medicines (PRN), the protocols for safe administration of PRN medicines were not available to staff. The registered manager told us they regularly reviewed PRN protocols, however failed to identify these were not available on the handheld devices used by staff. Staff told us they administered PRN medicines based on their knowledge of people, their behaviours and when possible, would ask a person would they like their PRN medicine. PRN medicine with varied dose would be administered to people based on staff’s judgment and when possible, people’s feedback. When regular staff were not working, there was no process in place to ensure people received their PRN medicines, for example when they were in pain. This placed people at risk of not receiving medicines in a timely way or being given medicines inappropriately. The registered manager contacted the manufacturer of the system to ensure the necessary adjustments were made and PRN protocols were available to staff.

Not all creams were dated when opened. All creams should be dated when opened to ensure the residents' safety and the medication's effectiveness, as most products have a limited shelf life after the original packaging is opened. Some people’s creams were left in places that were easily assessable by all. This meant there was a risk that people could ingest harmful substances. Some people’s medicine labels were worn out and hard to read. This meant information in relation to dosage, application instructions or who the cream belonged to was not always clearly visible and put people at risk of avoidable harm.

The provider’s quality assurance audits had failed to identify these shortfalls.

Staff were observed dispensing medicines without checking with the person if they consented to take it. Staff told us they would dispose of medicine if the person said they did not wish to take it.

Staff told us they were assessed on being competent in medicines. However, we found competency assessments were infrequent which meant the provider could not be assured staff were always giving medicines safely.

People and relatives did not raise concerns regarding medicine administration. A relative said, “I have no concerns regarding medication.”