Ingleborough House

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. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 demonstrated a proactive and positive culture of safety underpinned by openness, transparency and honesty. Staff consistently listened to and acted upon concerns about safety, and there were clear processes in place for reporting and investigating safety‑related events. Lessons learned were used to drive continual improvement and to embed good practice across the service.

For example, during the assessment a medication discrepancy was identified on the second day. The management team immediately completed a medication incident review to establish the cause and identify any lessons learned. Appropriate actions were taken to prevent a similar error occurring in the future.

The provider 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.

There were effective systems in place to support safe pathways and transitions of care. When a person first began receiving support, staff completed an initial assessment to identify their needs, risks and personal preferences.

Staff demonstrated good knowledge of people’s needs and told us they routinely reviewed care plans before visits. One staff member told us, “Through the care plan, that’s how I understand people’s needs,” and another told us, “Updates are communicated through handovers and staff meetings.” People and relatives also confirmed they were involved in care discussions, which supported smooth transitions when needs changed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on supporting people to improve their lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. People told us they felt safe. One person said, “Yes of course I am.” Another person said, “Yes I am, they [staff] look after me.” One relative told us, “I know [name] is looked after and is always clean and tidy.” Another relative told us, “Oh yes, I know [name] is safe, look at her smiling. I now have a quality of life because I know she is safe.”

People can only be deprived of their liberty to receive care and treatment with the appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which forms part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

Records demonstrated people were cared for in the least restrictive way, in line with and promoting the principles of the Mental Capacity Act (MCA) 2005. Deprivation of Liberty Safeguards (DoLS) authorisations were sought when required and any conditions imposed were followed.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care records informed staff about risks associated with people’s health and wellbeing, as well as the actions required to mitigate these risks. Risk assessments were in place for people, and these reflected their specific needs. For example, daily clinical meetings discussed people’s needs in relation to risk and what was in place to support them. One staff member told us, "Yes, care plans provide enough guidance."

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Maintenance logs showed repairs were addressed promptly, and daily environmental walk‑rounds were carried out to identify and respond to potential hazards.

The environment was safe, clean and well‑maintained. Records showed fire safety checks were completed weekly, and equipment checks were completed as needed. Personal Emergency Evacuation Plans (PEEPs) were in place for all people and reviewed to ensure they reflected people’s current needs. CCTV was used appropriately within communal areas, and its use was supported by a valid licence, ensuring compliance with data protection requirements. This was also evident in peoples care plans.

Staff demonstrated a clear understanding of their responsibilities in maintaining a safe environment. One staff member told us, “If we see anything around the home, we are told to report it.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Recruitment processes were safe. The documentation reviewed provided assurance that the provider carried out appropriate checks to confirm applicants were suitable to work with people who may be vulnerable.

Staffing levels exceed dependency requirements, providing flexibility across the home. Staff described strong teamwork and safe practice even during busier periods. One staff member told us, "Sometimes it’s busy but we work as a team, and all staff work as a team to help each other." Another told us, “Yes there is enough staff.” Relatives told us they had no concerns regarding enough staff. One relative told us, “This staff team are excellent, always working, always helping. Usually, two of them work together with some people and always helpful.

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. Staff demonstrated confidence in correct PPE procedures and appropriate waste disposal.

Equipment including slings, low beds and sensors were observed to be clean and allocated individually. IPC audits confirmed strong compliance alongside environmental cleanliness. One staff member explained: "We remove the gloves, the apron, mask and we would put it in the infectious bag."

The provider ensured medicines were managed safely and in a way that met people’s needs, capacities and preferences. People were involved in decisions about their medicines, including when changes were required.

Overall, medicines were managed well across the service. Systems supported safe administration and accurate record keeping. During the first day of assessment, we found a discrepancy between the electronic Medication Administration Record (eMAR) and the medication available for one person. The registered manager took immediate action in line with the service’s medicines management policy.

Medicines were stored securely and handled by staff who were trained and assessed as competent.

We spoke with the nurse about their approach when people refused prescribed medicines. The nurse explained that refusals would be explored sensitively to understand the person’s wishes and reasons. They stated they would discuss potential clinical alternatives with the GP, including different formulations such as switching from tablets to an oral liquid where appropriate, and ensure any changes were reflected in the person’s care plan and risk assessment. This demonstrated the nurse’s knowledge of safe medicines practice, supporting person‑centred care and positive outcomes for people.