This inspection took place on 12 November 2018 and was unannounced.

Ingersley Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home provides residential care to up to 46 people. During the inspection, there were 31 people living in the home, some of whom were living with dementia.

The previous registered manager had left the service and a new manager had been appointed and had been in post for seven weeks at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Feedback regarding the management of the service was positive and people told us they felt the service was improving.

The environment was not always safely maintained. Several safety issues were identified during the inspection, such as blocked fire exits which meant people would find it difficult to escape in the event of a fire and there were a number of items that people had access to that had the potential to cause them injury. We spoke with the manager about these issues and they were rectified during the inspection. Other safety issues could not be resolved on the day, such as risk of falls from a raised patio area that had insufficient security to prevent people from falling over them. However, following the inspection the manager confirmed these had been addressed.

People’s risks in the delivery of care had been assessed, but these assessments were not always accurate or reviewed regularly. This meant staff may not have accurate information about how to support people safely.

We looked at how medicines were managed within the home and found that safe medicine practices were not always adhered to. For example, the booking in and recording of medicines was not always accurate and the temperature at which medication was stored was not always monitored consistently to ensure medicines were stored at safe temperatures. Records showed that the manager had made some improvements to the management of medication within the home over the past few months and audits showed that less issues were being identified as a result of this.

We found that there were not always enough staff on duty to meet people’s needs in a timely way, especially at night. The provider acted on this straight away and increased the number of staff on duty at night and agreed to review the required number of staff during the day. Staff and people living in the home agreed that there were not always enough staff available.

Care plans were not always reviewed regularly and did not always reflect people’s current needs. This meant staff did not always have access to information on how best to support people.

Systems in place to monitor the quality and safety of the service were not always effective. The manager undertook a range of checks on the service but the checks undertaken had not picked up on all the concerns we identified during the inspection.

Records showed that safeguarding incidents had been referred to the local authority safeguarding team appropriately. However, CQC had not been notified of these issues. This meant the provider failed in their legal duty to keep CQC informed of issues that may have had an impact on the quality and safety of the care people received

Staff told us they always asked for people’s consent before providing care and when people were unable to provide consent, mental capacity assessments had been completed. These assessments were not always clear as to what decision needed to be made or who had been involved in best interest decisions. Thi