Ingleby 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 inadequate. At this assessment the rating has changed to requires improvement. 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.

There had been no registered manager since December 2023. Several managers had been involved in the management of the home since that time. Improvements had been made in relation to good governance. However, the provider needed to demonstrate further improvements and to sustain these, specifically in relation to quality assurance and provider oversight systems and processes to monitor and improve the quality and safety of the service. The provider remained in breach of legal regulation in relation to regulation 17.

This service scored 43 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

There had been several changes in management since the last inspection meaning there had been no consistent leadership presence to establish a shared vision and culture. Staff told us they felt supported by the senior care staff and the deputy manager but also commented on the changes in management.

A staff survey had been completed in May 2025. There was a low response rate from staff and scores were low in some areas. This included there being a friendly atmosphere at work, being able to speak with the manager when needed, finding the manager friendly and approachable and the manager leading by example. It was also acknowledged that there needed to be a permanent manager in place who could support the staff team over a long period of time and staff needed to be listened to in meetings and have a say.

The provider did not have consistent, inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation.

Changes in management meant leadership was not consistent or robust. Staff commented that there were too many managers involved, and they needed a permanent manager in post.

People told us they did not know who the manager of the home was.

Staff support and wellbeing had not been consistently provided by the organisation.

The provider gave the opportunity for staff to speak up. However, there was limited evidence feedback was acted on.

Staff surveys had been completed in May 2025 and although responses were few, staff had commented on the need for a permanent manager, to be listened to and to have a say. Whilst a manager had been recruited they were not yet in post and there had been no consistent manager since December 2023. No actions were recorded as being needed in relation to staff feeling they were not listened to.

Staff said they had raised the staff room being cramped and not meeting their needs on several occasions, but this had not been addressed.

Staff meetings were taking place.

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.

There was a diverse workforce which included international staff. One staff member told us how they made sure the staff room was available at specific times for a colleague who had particular cultural needs. Some traditional events were celebrated such as VE Day.

There was limited supervision and support for all staff, including international staff however a plan was in place to ensure staff received supervision and appraisal in line with the providers policy moving forward.

An Equal Opportunities Policy was in place and had a review date of January 2022. However, there was no evidence it had been reviewed. Staff had attended equality and diversity training.

The provider 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.

There had been no registered manager in post since December 2023 and during this time there had been multiple managers involved, including peripatetic managers and regional managers. Improvements had been made to the quality assurance systems. However, there was no consistent oversight due to the number of managers being involved in the home.

Audits were evidence based, and there was space within the audits to record comments on the evidence used to assess the quality of the service, but this was not always documented. Some audits had clear action plans, with the roles of the people responsible and target dates, others did not. A validation process was in place whereby actions were ‘validated.’ At times, this was completed on the same day as the audit and had not recognised that more detail was required to ensure a robust, and consistent approach.

A quality assurance policy was in place with an issue date of March 2023 and a review date of March 2025. However, there was no evidence it had been reviewed.

Some areas identified at that last inspection as needing to improve had not been fully implemented by the provider, including the inclusion of people and legal representatives in decisions about their care.

The provider continued to collaborate and work in partnership with key stakeholders.

Staff continued to comment on inconsistent management of the home and people told us they were not sure who the manager was.

Whilst some improvements had been made since the last inspection, they needed to be fully embedded and sustained.

The providers systems for learning and improvement were still not always effective.

Some improvements had been made by the provider. However, there were continued shortfalls in relation to inclusion, care planning and risk management, staff support and the embedding of the quality assurance system.

Multiple managers from the organisation were involved in the quality assurance process meaning the responsibility and accountability for learning and improvement was shared, with no one person in control of maximising its effectiveness.