CQC report explained · a nursing home
What the CQC found at Ingleborough Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Creams and ointments were not always recorded correctly, and guidance for as-needed medicines was not detailed enough. Fire safety actions were overdue and a window restrictor had not been identified by checks, although this was fixed during the inspection.
- Effective?
- Requires improvement
- Care plans and risk assessments were not always reviewed on time or updated with current information. Training was available and staff were competent, but training records were not always accurate.
- Caring?
- Good
- This key question was not inspected in this report. People told inspectors they were happy with the care and felt safe.
- Responsive?
- Good
- This key question was not inspected in this report. The report says people had personalised bedrooms and could choose meals, drinks and snacks.
- Well-led?
- Requires improvement
- Quality checks had not identified some problems, including medicines and the window restrictor. The home was not regularly seeking feedback from people, families or staff, and known fire safety actions had not been completed promptly.
What inspectors found, October 2022
Ingleborough Nursing Home was rated Requires Improvement; inspectors found risks with medicines, fire safety, care records and quality checks.
This was an unannounced inspection on 08 August 2022. Two inspectors and an Expert by Experience spoke with seven people, two relatives and five staff. They reviewed care, medicine, recruitment and management records.
The home was not always safe or effective. Creams and ointments were not always recorded as given, some risk assessments and care records were out of date, and actions from a fire risk assessment and fire drills had not been completed promptly. A window without a restrictor was made safe during the inspection.
People said they felt safe and were happy with their care. Staff were safely recruited and given a thorough induction. People enjoyed the food, had choices and were supported to eat and drink. Infection control arrangements were satisfactory.
The overall rating changed from Good at the previous inspection to Requires Improvement. The home must improve its medicines management, safety arrangements and checks on the quality of care. The report says a new manager had plans for improvement, but the new systems were not yet in place during the inspection.
Safe recruitment and induction
Staff were safely recruited and received a thorough induction before working with people. Inspectors found staff knowledgeable and competent in their roles.
“Staff were safely recruited and received a thorough induction and support before working with people.” from the report
Food and choice
People were offered a choice of meals, drinks and snacks. Staff encouraged independence and provided help when needed.
“People were supported to eat and drink in a safe and enjoyable way.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infections, including the use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
People felt safe and cared for
People told inspectors they felt safe and were happy with the care they received. The report also records positive feedback from a family member.
“People told us they were happy with the care they received.” from the report
Mental capacity practice
Where people lacked capacity, assessments and best-interest decisions were recorded. Staff asked for consent and applications for legal safeguards had been made where needed.
“Assessments had been completed when people lacked capacity and best interest decisions were recorded as required.” from the report
Medicines records and instructions
seriousRecords for creams and ointments did not always show whether medicines had been applied. Instructions for as-needed medicines were not detailed enough for staff to follow safely.
“Records relating to the administration of topical medicines (TMARs) had not always been completed to show that items such as creams and ointments had been applied to people when required.” from the report
Fire and environmental safety
seriousActions from a 2019 fire risk assessment and issues found during fire drills were still outstanding. A window was not restricted, creating a risk of falling from height, but the provider fixed this during the inspection.
“Actions raised on a fire risk assessment in 2019 had not been completed in a timely manner and were still outstanding at the time of the inspection.” from the report
Out-of-date care information
seriousCare records and risk assessments did not always contain the latest relevant information. It was sometimes unclear whether people were receiving the support needed to prevent harm.
“Care records and risk assessments did not always contain the most up to date relevant information available.” from the report
Weak quality checks
seriousThe home's audits did not identify some problems and known issues were not dealt with promptly. The home was also not regularly seeking feedback from people, families or staff.
“The provider failed to assess, monitor and improve the quality and safety of the service.” from the report
- 01How are creams, ointments and as-needed medicines now recorded and checked?
- 02Have all actions from the 2019 fire risk assessment and recent fire drills been completed?
- 03How are care plans and risk assessments kept up to date, especially for repositioning and food and fluid support?
- 04What changes have been made to the audits and quality checks since this inspection?
- 05Has the planned refurbishment started, and what work has been completed?
This inspection focused on Safe, Effective and Well-led; Caring and Responsive were not inspected, and the report says ratings for uninspected questions are carried over from the previous inspection. This explanation was written from the published report of 14 October 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, October 2021
Inspected but not rated; inspectors found good infection-control measures but several COVID-19 practice shortfalls needing immediate action.
This was an announced, targeted inspection on 27 August 2021. It looked only at infection prevention and control because the home was experiencing a COVID-19 outbreak.
Inspectors found that the home was testing people and staff, managing admissions safely and limiting movement between units. They were assured about visiting arrangements, shielding and social distancing.
However, some risk assessments and audits were not up to date. Masks were not always changed correctly, cleaning arrangements were incomplete and some staff lacked suitable training. The provider took immediate action during or after the inspection.
The home was inspected but not rated. This means the report does not give an overall quality rating or a rated judgement for the five key questions.
Regular testing
People and staff were tested regularly, helping the home identify COVID-19 cases promptly.
“People and staff were tested regularly which helped identify cases of COVID19 in a timely manner.” from the report
Safer admissions
The home had processes for admitting people safely and was limiting movement between units.
“Systems and processes were in place to safely admit people to the home.” from the report
Social distancing
Inspectors were assured that the home was following shielding and social distancing rules.
“We were assured that the provider was meeting shielding and social distancing rules.” from the report
Out-of-date risk assessments
seriousSome risk assessments did not reflect the risks from the outbreak. Audits had been completed, but they did not always lead to action or identify problems found by inspectors.
“Risk assessments for staff and people were not always up to date.” from the report
PPE practice
seriousStaff were wearing PPE, but masks were not always changed and disposed of as current guidance required. The provider acted immediately after this was raised.
“However, masks were not changed and disposed of in line with current government guidance.” from the report
Cleaning and training
seriousThe home was clean, but cleaning schedules and correct cleaning methods were not always in place. Some staff had not received appropriate infection-control training.
“The home was clean however, there was a lack of cleaning schedules in place and the correct chemicals and cleaning methods were not always used.” from the report
Management direction
needs fixingInspectors found that staff had not always received clear guidance about managing the outbreak. The provider took action to address this.
“There was a lack of direction provided to the staff team by the registered manager about how to effectively manage the outbreak.” from the report
- 01What changes have you made to keep risk assessments up to date during and after an outbreak?
- 02How do you check that staff change and dispose of masks correctly?
- 03Are cleaning schedules, chemicals and cleaning methods now checked regularly?
- 04Which staff have completed infection prevention and control training, and how is this monitored?
- 05How do managers make sure current infection-control guidance is clearly communicated to all staff?
This was an announced, targeted inspection of infection prevention and control during a COVID-19 outbreak; it did not assess the other areas of care or provide an overall rating. This explanation was written from the published report of 5 October 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Ingleborough Nursing Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2021Inspected but not ratedSafe: Inspected but not rated
- March 2020Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- March 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015
Report published without a new overall rating.
- September 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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