Inglewood Residential Rest Home improved from Requires Improvement to Good following a focused inspection of the Safe and Well-led key questions, having addressed previous breaches of Regulation 17 around governance. The service demonstrated robust medicines management, effective risk assessment, strong safeguarding processes, and a well-led culture under an engaged registered manager.
Strengths
· Medicines stored safely with lockable facilities, refrigeration, and daily temperature checks
· Risk assessments reviewed regularly and updated following incidents such as falls
· Robust safeguarding systems with staff trained to recognise and report abuse
· Staffing levels exceeded dependency tool requirements; staff had time for one-to-one interaction
· Effective infection prevention and control practices in place
Inglewood Residential Rest Home was rated Requires Improvement overall following a focused January 2023 inspection, with a continued breach of Regulation 17 (Good Governance) resulting in a warning notice due to ineffective quality assurance systems failing to identify and address risks around falls, pressure care, continence monitoring, medicines storage, and the absence of formal staff supervision. Strengths included adequate staffing, a positive and open culture, good safeguarding practices, effective infection control, and strong partnership working with healthcare professionals.
Concerns (6)
criticalGovernance: “The provider's quality assurance systems and processes were not effective. They had not enabled them to identify and address the concerns we identified at this inspection”
moderateCare planning: “where people were assessed to be at high risk of falls, staff had not always been provided with clear information and guidance, in people's support plans or risk assessments”
moderateRecord keeping: “monitoring charts were not consistently completed, indicating people may not receive consistent support and monitoring. This meant people were at increased risk of developing skin damage.”
moderateMedication management: “People's medicines were not always stored safely. We observed that whilst a member of staff was administering medication, doses of 2 laxative medicines were left on top of the medicines trolley unattended.”
moderateSupervision / appraisal: “There was no formal system of one-to-one staff supervision in place. The registered manager confirmed this. This meant there were missed opportunities to review staff performance”
minorPerson-centred care: “The premises had not been fully adapted to the needs of people living with dementia. For example, there was no directional signage to key areas and rooms to help people with dementia navigate”
Strengths
· Adequate staffing levels maintained day and night, with consistent agency staff used to promote continuity of care
· Robust safeguarding training in place; staff able to recognise and report abuse and people reported feeling safe
· Accidents and incidents monitored effectively via a new system introduced October 2022 with learning shared across staff
· Medicines administered by trained and competency-assessed staff with detailed PRN protocols in place
· Positive, open culture promoted by registered manager; staff felt supported and worked well as a team
Quality-Statement breakdown (17)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentGood
safe: Learning lessons when things go wrongGood
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Adapting service, design, decoration to meet people's needsRequires improvement
effective: Staff working with other agencies; supporting people to access healthcare servicesGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Assessing people's needs and choices; delivering care in line with standardsGood
well-led: Managers and staff being clear about their roles; quality performance, risks and regulatory requirements; continuous learningRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood