Ingleby 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 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 provider had made improvements since the last inspection, and they were no longer in breach of legal regulations in relation to safe care and treatment, the management of medicines and duty of candour

Improvements had been made in relation to good governance however the provider remained in breach of legal regulation in relation to regulation 17. There was limited evidence of people’s involvement in care plans and risk management. Staff had not received consistent supervision and annual appraisals had not taken place.

This service scored 56 (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 have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Staff commented about the inconsistencies in management. People told us they did not know who the manager was.

Staff surveys were completed. However, limited action was taken to address concerns raised, for example in relation to the atmosphere in the home.

Complaints had been investigated; however, the current management team were unable to find the outcome of a complaint made in relation to care planning and care provision.

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.

People and their legal representatives were not included in the care planning process. Inconsistencies in care records and risk assessments meant the monitoring of care was not robust. One person was living with epilepsy yet there was no care plan or risk assessment in place. This was completed in response to our feedback.

Appropriate referrals to healthcare professionals were being completed in a timely manner.

The staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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. The provider shared concerns quickly and appropriately.

Staff had attended safeguarding training and were knowledgeable about indications of harm and abuse. All the people we spoke with told us they felt safe. Comments included, “I feel safe here” and “The girls here are so nice and make me feel safe.”

The provider did not always work well with people to understand and manage risks.

Risks were assessed using recognised tools. However, there continued to be limited evidence that people, and/or their legal representatives were involved in the process.

Risks to one person in relation to seizures had not been assessed. This was addressed during the inspection.

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

Safety checks of the premises and equipment were completed. The provider had identified some issues with window restrictors and had ordered new window restrictors, however, the incorrect restrictors having been received. No risk assessments had been completed to mitigate any risks whilst waiting for the appropriate restrictors. The provider confirmed during the inspection the correct window restrictors were now in place.

The provider did not always make sure staff received effective support, supervision and development. The recording of DBS checks as part of safe recruitment processes was not robust. There were mixed views in relation to whether there were enough staff to provide safe care for people.

The interim home manager had completed one supervision meeting with each staff member. However, staff had not received supervision in line with the provider's policy. There was no evidence annual appraisals were taking place. A schedule was in place to ensure staff received supervision and appraisal with the provider's policy moving forward.

DBS checks were completed as part of the recruitment process. The type of DBS check, the date of the check and who viewed the certificate was not documented.

Staff told us they needed more staff over the weekends, and that the first floor was understaffed. There were mixed views from people with some commenting, “There appear to be enough staff” and another person said, “There aren’t enough staff” and “they are definitely short staffed.” Observations were mixed, on day one there was only one senior care worker covering both floors. During the mealtime experience on the first floor there was only one staff member in the dining room which impacted the support people received.

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 home was clean and tidy. Task orientated schedules were in place for cleaning, including the cleaning of specialist equipment.

Personal protective equipment was appropriately worn and staff understood procedures for safe donning and doffing.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences.

Improvements had been made to the management and administration processes for medicines.

Medicines were stored securely with access restricted. Clinic rooms were tidy with no excess of medicines. Medicines requiring storage in a fridge were now monitored in line with manufacturers guidance. Equipment and utensils used to support the administration of medicines were in place and clean.

The home now had a process for the handling of waste medicines, and this was being followed by staff. Improvements had been made to the oversight and monitoring of controlled drugs.

Some medicines have a reduced expiry date once opened. Where these were used the date of opening was not recorded.

Improvements had been made in the use of topical medicines, thickeners and as required and variable dose medicines. However, further work was needed to embed these changes.

Patch application records were not completed accurately for two people. Further work was needed to improve and embed the use of and recording of patches.

Audit processes were in place. However, it was not clear which audit process staff were following and therefore further work was needed to ensure a clear audit process was in place.