Background to this inspection
Updated
4 August 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
This inspection was carried out by one inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Ings Grove House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Ings Grove House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
At the time of our inspection, there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
Inspection activity started on 23 June 2022 and ended on 11 July 2022. We visited the location’s office/service on 23 June and 5 July 2022.
What we did before the inspection
We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections.
We reviewed information we held about the service, including information about important events which the service is required to tell us about by law. We requested feedback from other stakeholders. These included the local authority safeguarding team, commissioning team, infection and prevention control team and Healthwatch Kirklees. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all of this information to plan our inspection.
During the inspection
We spoke with seven people using the service and seven relatives about their experience of the care provided. We observed care in the communal areas to help us understand the experience of people. We received feedback from three healthcare professionals.
We gathered information from several members of staff, including the registered manager.
We reviewed a range of records. This included three people's care plans, risk assessments and associated information, and other records of care to follow up on specific issues. We also reviewed multiple medication records. A variety of records relating to the management of the service, including policies and procedures were also reviewed.
After the inspection
We looked at three staff files in relation to recruitment and training. We continued to seek clarification from the provider to validate the evidence found.
Updated
4 August 2022
About the service
Ings Grove House is a care home which can support up to 40 people. The home provides intermediate care, which supports hospital discharge through rehabilitation to help people regain previous levels of independence. At the time of the inspection, there were 24 people using the service.
People’s experience of using this service and what we found
The service was not always managed well. Quality assurance systems were in place and happening regularly, however these had not always been effective in identifying the issues found at this inspection. Improvements were required to ensure records in relation to people’s care were complete and accurate. This area had already been identified by the registered manager as requiring improvement.
Medication was not always managed safely. We found concerns in relation to the management of ‘as and when’ required medicines and thickeners. There had been several medication errors at the service and although none had a detrimental impact on people’s health, there was a high risk lessons were not being learnt to prevent reoccurrence.
We received mixed feedback from people and staff in relation to the staffing levels at the service. We reviewed the time of response to call bells and found examples of this being responded to over the expected time set by the registered manager. Some of these issues had already been identified by the registered manager, others had not. We recommend the provider reviews their staffing levels, taking into consideration dependency levels, call bell response times and the layout of the building.
People and relatives told us the care received at the service had a positive impact on people. People told us they felt safe and enjoyed being at the service; their comments included, “[Coming to Ings Grove] was the best thing that ever happened.” Relatives shared positive feedback as well.
People were supported to have maximum choice and control of their lives, and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Throughout the inspection the registered manager was honest and open with us. They acknowledged the shortfalls identified at this inspection and were eager to put processes in place to ensure people receiving care and support were safe and protected from harm.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published on 24 October 2019).
Why we inspected
This was a planned inspection.
We have found evidence the provider needs to make improvements. Please see the safe and well led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.
We have identified breaches in relation to safe care and treatment and good governance at this inspection.
We made a recommendation for the provider to review good practice guidance in relation to safe staffing levels.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.