Ingleside Residential Care Home

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 good. At this assessment the rating has changed to requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

There was a lack of oversight from the management team to ensure people’s needs were supported appropriately and people were engaged in a way that was meaningful to them. Management did not demonstrate the required skills or capability to ensure risks were well managed such as having effective oversight of staff practice. Audits we looked at were ineffective and did not identify the concerns we found, the management team lacked appropriate training and the skills to ensure audits were completed correctly . This meant risks to people’s safety were not always effectively assessed.

The provider failed to recognise the culture at the service did not promote or uphold people’s rights. For example, people were not involved in planning their care. Nor was there a system in place to ensure people’s feedback was sought. These shortfalls had not been identified by the management team.

The provider started to make necessary changes as a result of our feedback. These changes need to be embedded into practice and sustained.

Staff spoke positively about the registered manager and told us they felt able to ask for support if needed. One staff member told us, “The registered manager is more than approachable. Always happy to talk about problems and sort them.” Another staff member said, “The registered manager is very approachable, ready to listen and supportive.”

The registered manager was respected and well-liked. Staff told us they knew how to raise concerns and access support.

Staff told us they knew how to whistle blow, and report concerns to external organisations if necessary. They understood duty of candour and their responsibilities.  The duty of candour is a general duty to be open and transparent with people receiving care.

Staff told us they were aware they could report any concerns they had externally to the local authority or CQC. One staff member said, “If I was concerned that somebody may be being abused, I would report this immediately within the home to the senior staff member on duty or my manager, following the organisation’s safeguarding policy. I would also report concerns outside of the home to the local authority safeguarding team, and if required, to the CQC or emergency services if there was immediate danger.” Another staff member told us, “Inside the home I would report to the registered manger or a senior member of staff, outside the home I would report to adult social services.”

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

Staff told us they enjoyed working at the service and felt supported. A staff member said, “We have one to one meetings and we can ask for meeting to speak to the management when needed if there are concerns that need to be spoken about straight away. Staff will go to the office and ask if we can have a word, we can put things in writing if needed too.”

Staff had equality and diversity training.

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

The provider did not have effective oversight of quality and risk in the service which meant people were at risk of potential harm. The provider’s governance and monitoring systems were ineffective and failed to recognise a range of shortfalls in people’s care delivery and the running of the service. The systems and processes that were in place were often completed incorrectly. This limited the provider’s ability to improve the quality of life for people using the service. During this inspection we raised several concerns with the local safeguarding authority.

The provider did not have effective oversight of people’s weights and airflow mattress settings. This meant they could not be assured the airflow mattresses were used correctly. This placed people at risk of avoidable harm.

The provider did not have an effective system in place to ensure recruitment processes were followed. This meant some staff did not have all the required pre-employment checks in place which is a statutory requirement. This place people at risk of potential harm.

The provider and management team had no oversight of care provision. There were no records of written handovers. The registered manager told us staff completed handovers verbally. The provider and the registered manager did not ensure people’s MCA assessments were completed.

The provider had failed to identify the fire safety shortfalls we identified during this inspection. This placed people at avoidable risk of harm in case of an emergency.

The provider’s own governance systems failed to identify and act on shortfalls in medicine management we found during this inspection.

The processes and systems in place to ensure appropriate numbers of staff were available, were not robust and failed to identify there were not enough staff to meet people’s assessed needs.

Services we regulate have a statutory responsibility to notify CQC about certain events that occur in a service. We found the provider had not always submitted notifications in line with the regulation. Notifications are important because they support us to monitor the services we regulate.

A staff member said, “I feel the management is poor because I’ve seen no improvement to the home since I started working here.”

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

Staff told us they communicated with health and social care professionals as required.

Health and social care professionals were complimentary about working with the service.A professionals said, “The team at Ingleside know their patients well and are aware of changes in their condition and escalate concerns appropriately. They identify and accommodate the needs and preferences of individual residents effectively, they treat them as individuals and respect their personal preferences. Over the years I have worked with the team at Ingleside they have been open to feedback, and I have found that they are keen to work together to ensure that their patients receive good care.”

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider and the registered manager did not have a good understanding of how to implement improvement actions. There were no processes in place to ensure that learning happened when things went wrong. A learning culture was not embraced within the service to ensure people’s safety was a priority. For example, incidents and accidents were not effectively monitored which meant opportunities were missed to learn lessons and prevent reoccurrence. The provider missed the opportunity to learn and improve from people’s feedback, complaints and from governance processes.

Our inspection found widespread and significant shortfalls which were not identified or addressed through the provider’s quality management systems.