About the service: Ingham Old Hall is a residential care home that provides personal care and support for up to 25 people aged 65 and over. There were 15 people living at the service at the time of the inspection. Most people were living with dementia.

People’s experience of using this service:

People who live at Ingham Old Hall were not always having their needs met by sufficient numbers of suitably trained staff. Ongoing environmental risks and concerns around medicines management remained. Leadership and governance arrangements within the service still remained of concern, as they were not identifying shortfalls and making changes to address them. There continued to be breaches of regulation, and the service was not fully meeting the conditions placed on their registration.

The service was not consistently sourcing or following advice from healthcare professionals, particularly in relation to meeting people’s pressure care needs. We identified gaps in recording of care tasks including repositioning people, providing oral hygiene and personal care, therefore we were unable to source assurances people’s care and support needs were being fully met.

People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; policies and systems in the service were not followed to support good practice.

Improvements had been made to the cleanliness of the care environment to make it more comfortable. People were accessing more activities. Staff showed more kindness and compassion at this inspection.

Management plans were in place for people needing support at the end of their life. Further end of life care training was scheduled for 2019. The service was working hard to improve relationships with other organisations to ensure people received joined up care.

Improvements had been made to encourage people to give feedback on the service, and areas for improvement.

Rating at last inspection: Ingham Old Hall was last inspected 13 and 14 June 2018. As an outcome of the inspection the service was rated as Inadequate and placed in special measures. The last inspection report was published 27 November 2018.

There was a breach of Regulation 9, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 resulting in us imposing conditions on the service’s registration. There was a breach of Regulation 10, 11 and 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 resulting in us issuing requirement notices. The service has been providing monthly improvement plans to CQC, and this information was reviewed as part of this inspection.

Why we inspected: The service was placed in special measures, as an outcome of being given an overall rating of Inadequate. Services placed in special measures are inspected within six months of the publication date of the report to determine if sufficient levels of improvement have been made.

Enforcement: At the last inspection, we identified seven breaches of regulation, and took enforcement action.

At this inspection, we identified repeated breaches of regulation 11, 12, 17 and 18. The service was not fully meeting the conditions placed on their registration. Full information about CQC's regulatory response to any breaches of regulation found during inspections is added to reports after any representations and appeals by the provider have been concluded.

Follow up: We will continue to monitor this service and will reinspect in line with our schedule for those services rated as Inadequate. As an outcome of this inspection, the decision was made for the service to remain in special measures.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The inspection took place on 13 and 14 June 2018 and was unannounced.

Ingham Old Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC (Care Quality Commission) regulates both the premises and the care provided, and both were looked at during this inspection.

The service provides accommodation and care to a maximum of 25 people. At the time of the inspection 22 people were living at the home, some people were living with dementia. One person was staying for temporary respite care.

There was a manager in post, who had applied to CQC to complete the registration process, but was not registered 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.

At our last comprehensive inspection on 3 and 4 May 2017 we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of the regulations for safe care and treatment and good governance. A follow up focussed inspection was completed 25 July 2017 to review medicines management in relation to the breach of regulation for safe care and treatment. The service was found to no longer be in breach of regulation.

During this inspection we identified that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of the regulations for safe care and treatment including the condition of the care environment and equipment used, protection of people’s privacy and dignity, adherence to the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards, management of people’s nutritional and hydration needs, good governance and safe staffing.

During this inspection, we identified areas of concern in relation to staff competency in safe management of medicines, cleanliness of the environment and infection prevention control impacting on the care people received.

The service did not have robust governance processes in place for monitoring standards and quality of care provided. Staff did not complete clinical audits in areas such as medicines management and the condition of the environment and this was reflected in our findings during the inspection.

Staff were not up to date with the provider’s mandatory training or annual performance appraisals. Staff did not receive regular supervision to review their performance and areas of improvement. The management team did not have robust oversight of staff performance. We saw examples of where training and good practice was not being implemented in the care and treatment of people living at the service.

People’s records demonstrated a lack of adherence to the Mental Capacity Act and Deprivation of Liberty Safeguards. It was unclear if people’s movement was lawfully restricted and this was a potential infringement of their human rights.

Low staffing levels impacted on people’s access to meaningful activities and maintenance of hobbies and interests. There was not a daily activity timetable, and people told us they often felt “bored”.

People were not consistently treated with care and compassion, and their privacy and dignity was not routinely protected. We saw examples of people being hoisted in communal areas, resulting in their underwear and continence products being on show to others.

Due to level of risks identified from this inspection, we wrote to the provider under Section 31 of the Health and Social Care Act 2008, to request for provision of an action plan to address our concerns. An action plan, with clear dates for completion of

We carried out an unannounced comprehensive inspection of Ingham Old Hall Care Home on 3 and 4 May 2017. Two breaches of legal requirements were found. After the comprehensive inspection, a warning notice was served in relation to the management of medicines.

We undertook this focused inspection in July 2017 to check that the service had met the warning notice and to see whether they now met legal requirements. This report only covers our findings in relation to the warning notice. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ingham Old Hall Care Home on our website at www.cqc.org.uk.

Ingham Old Hall Care Home provides care and support for to up to 25 older people, some of whom may be living with dementia. The home is a converted period building, over two floors, set in extensive grounds. Some rooms have en suite facilities. At the time of this inspection, there were 23 people living in the home.

There was a registered manager in post. 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.

At the last inspection carried out in May 2017, we asked the provider to take action to make improvements in the management of medicines. At this inspection we found that these actions had been completed although a period of sustained improvement is required in order for us to have confidence that these changes have been imbedded into everyday practice.

Medicine management audits had been introduced since our last inspection and these had helped to ensure people received their medicines safely and as the prescriber had intended.

Staff had received up to date training in medicine administration and handling and their competency to do so had been assessed.

Frequent audits had helped staff to account for medicines which we found to be mostly accurate. However, whilst this had improved since our last inspection, we found some minor numerical discrepancies in records for the receipt of medicines.

Supporting information for medicines administration had also improved which further assisted in people receiving their medicines safely. This included the recording of personal information about people’s medicine administration, the safe handling of eye drops, guidance for staff on medicines taken on an ‘as required’ basis and records relating to pain-relieving skin patches.

At this inspection, we concluded that sufficient improvements had been made by the service and they were no longer in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The inspection took place on 3 and 4 May 2017 and was unannounced.

Ingham Old Hall Care Home provides residential care for up to 25 people, some of whom may be living with dementia. The home is a converted period building, over two floors, set in extensive grounds. Some rooms have en suite facilities. At the time of our inspection, 24 people were living in the home.

At the time of our inspection, the service had a registered manager who had been in post for a number of years. 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.

We last inspected this service in July 2016 where we found that the service was not meeting one requirement of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach related to the management of people’s medicines. The provider sent us information to tell us about the actions they were going to take to rectify the breach of the regulations. They gave no timescale for the completion of the actions they proposed. At this inspection, carried out in May 2017, we found that the service had not made the required improvements and were still in breach of this regulation. The service was also found to be in breach of the regulation associated with governance. In addition, we have made recommendations about staff training on the subject of the MCA and recording risks.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Records did not demonstrate that people had received their medicines safely, appropriately and as the prescriber had intended. Good practice guidance had not been consistently followed.

The system the provider had in place to assess and monitor the medicines management and administration within the home had not been effective at rectifying the issues found at this, and our previous, inspection. No formal audits were in place to help drive improvement in other areas of the service.

Processes were in place to help prevent and protect people from the risk of abuse and harm. Staff understood safeguarding procedures and any risks to those that used the service had been identified and managed. However, records did not always robustly demonstrate this.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. No overly restrictive practices were identified however the service did not demonstrate full compliance with the MCA.

The service had processes in place to help reduce the risk of employing staff not suitable to work within the home. New staff received an induction, were encouraged to gain health and social care qualifications and received ongoing training. They received regular support to assist them in their roles.

Good team work was evident and the home ran smoothly with a relaxed atmosphere. Staff told us that they were happy working at Ingham Old Hall Care Home. Those that used the service trusted the staff that provided them with care and support.

Staff respected each other and those that used the service. They demonstrated a patient, caring and considerate approach to all those they interacted with. Care and support was provided in an unhurried and relaxed manner suitable to each individual.

People had choice in how they spent their day and staff supported them in making decisions. Independence was supported and dignity considered and maintained. Care was delivered in a discreet manner.

The risks associated with the environment had been identified and managed. However, records did not consistently and robustly record what preventative measures the service was taking in regards

The inspection took place on 6 and 7 July and was unannounced.

Ingham Old Hall provides residential care for up to 25 older people some of whom may be living with dementia. At the time of this inspection there were 23 people living within the home. The accommodation is over two floors with most rooms having either en-suite facilities or a dedicated bathroom. A number of communal areas, a conservatory and extensive gardens and grounds were also available.

There was a registered manager in post. 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.

The management of medicines did not follow good practice and the records we viewed did not demonstrate that people had received their medicines as the prescriber had intended.

People benefited from receiving care from staff that felt supported and valued in their roles. Staff had received an induction that was flexible to their needs and received ongoing training. Training was delivered in a variety of forms to suit differing learning styles. Staff received regular support sessions called ‘job chats’. Staff worked well as a team and morale was good. Colleagues supported one another.

People received care and support that was kind, considerate and caring. Staff were respectful and courteous to the people they supported and others. People’s dignity and privacy was maintained and staff understood the importance of respecting confidentiality. People had choice in their lives and their independence was encouraged.

The risks to be people had been identified, assessed and appropriately managed. Accidents and incidents had been recorded and analysed to prevent further occurrences. Staff had a good understanding of what constituted abuse and knew how to report any concerns they may have. Processes were in place to help protect people against the risk of abuse.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Staff understood how the MCA and DoLS impacted on their work and those they supported. The service had made appropriate DoLS applications and demonstrated adherence to the MCA.

People had been involved in planning the care and support they needed and wanted. Care plans were accurate, reflected people’s individual needs and had been assessed as required. People told us their needs were met and that they received the care and support they required at a time they requested. Staff demonstrated a person-centred approach in caring for people.

People’s social and leisure needs were met in an individualised manner. Meeting people’s social and leisure activities were incorporated into every staff member’s daily role and this was demonstrated at inspection. People had had the opportunity to contribute to a life history and lifestyle document to assist staff in building meaningful relationships with the people they supported.

The service met people’s healthcare and nutritional needs. People had access to a variety of healthcare professionals and records demonstrated that interventions had been sought appropriately and promptly. People received enough of the food and drink they liked and required.

The home had a system in place to monitor the quality of the service being delivered and this was effective in most areas. The system had failed to identify some of the issues associated with the safe management of medicines however the registered manager took immediate action to address this.

The people we spoke with respected the management team and had confidence in them. They described them as visible, approachable and supportive. Systems were in place that demonstrated the service strove for improvement and continuous development

We conducted this inspection to establish the following about Ingham Old Hall Care Home: Was the service safe? Was it effective? Was it caring? Was it responsive and was it well-led?

Below is a summary of what we found. This summary is based on our observations during the inspection, speaking with people who used the service, their relatives, the staff supporting them and from reviewing records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Most of the people we spoke with who lived at Ingham Old Hall told us that they felt safe and secure and that staff treated them with respect and dignity. Some people we could not communicate with but we did observe and note how they were treated, how they were looked after and what efforts were made to keep them safe.

People we were able to speak with told us that they knew who to speak to if they didn’t feel safe or were unhappy about something. They indicated that staff took great care to ensure that they felt secure in their surroundings.

We spoke with family members of one person we spoke with. They said "It was a very good admission process. It caused a lot of heartache for us though. We were worried about them not fitting in, but we needn't have worried. Friends were made almost straight away. Staff are excellent too."

We inspected the staff rotas and found that there was sufficient staff on duty to meet people's needs throughout the day and night. The home was clean and maintained to a satisfactory standard. We found that staff were trained and supported to do their job safely.

Ingham Old Hall had a daily programme of identifying and rectifying maintenance requirements. This meant that people were not exposed to unnecessary risk.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards [DoLS] which applies to care services. We reviewed applications up to and including July 2012. No applications had been made since that date. All applications were documented, signed, dated and with witness statements where applicable. Adequate policies and procedures were in place relating to DoLS. Staff had been trained to understand when an application should be made and how to submit one.

Is the service effective?

Ingham Old Hall demonstrated that it took great care to ensure the care and wellbeing of the people using the service. This was shown in individual care records, up-to-date and current risk assessments, daily reports and communication records. We saw evidence of people having been involved in decisions about their care, where this was possible, and that their needs and wishes were known.

There was a system of recording and managing incidents concerns and complaints which was managed by the manager. We saw evidence of how the home responded to issues, or requests, which resulted in the home increasing its levels of effectiveness and satisfaction. For example there was an internal policy of replacing worn equipment immediately.

Is the service caring?

Ingham Old Hall operated an ‘open door’ policy to people living at the service, their families and staff. The manager told us "If anyone had any concerns or issues about the care provided, the door was always open to discuss it.”

We noted that people were supported respectfully and courteously. We particularly noted that people were spoken with in a polite manner by staff. Smiles and words of comfort were offered and interactions seen to be understood by the person spoken with.

We saw evidence that care records were reviewed on a monthly basis or more frequently if required. Reviews with people using the service and their family members were also noted to take place. This told us that the home took reasonable steps to work with families to deliver care in a way which was both satisfactory and re-assuring.

Care and support provided was as individual and informative as it could be. We noted that other healthcare professionals worked with the home to ensure continuity of care where necessary.

Was it responsive?

We saw that the home responded to people on an individual basis. People’s likes/dislikes were acted on and we saw every effort made to put the interests and wellbeing of the individual first.

One person we spoke with said “I had to live somewhere and as it turned out, this was the best place for me. It was hard at first but now I'm settled and happy.”

We saw staff responding to people's needs and questions in a proficient manner. We noted that whilst staff were busy that they still took time out to re-assure people, interact with them and generally engage with them.

We saw evidence that staff had individual knowledge of each person and their care requirements, for example, how best to communicate with them, their likes, dislikes, dietary requirements and behavioural challenges. We noted that comments and thoughts were shared in daily records and shared across the management and care teams as part of ongoing reviews.

Was it well-led?

Ingham Old Hall runs and maintains a quality assurance system. The quality assurance system in place was robust. Learning from incidents/complaints was recorded and shared and any shortfalls in service provision put right.

We found that people’s personal care records, and other records kept in the home, were accurate, safe and filed appropriately and securely.

We also noted that management and senior carer staff at Ingham Old Hall had agreed to take part in a regional dementia care coach programme. This illustrated their commitment to service users who were living with dementia.

Our inspection was unannounced, which meant that no one knew that we would be visiting. There were twenty people living at the home on the day of our inspection. During our visit to Ingham Old Hall we toured the premises, saw people using different parts of the building and garden. We spoke with five people and five members of staff. We saw how an exercise class was carried out for people who wished to take part with this organised event. We observed how people were treated and how staff interacted with them. We saw staff knocking on bedroom doors before entering and how they treated people respectfully. People appeared relaxed and content within their surroundings.

We saw that people were cared for effectively and that the care was planned for the individual. We saw that people were safe and that there were sufficient suitably qualified and experienced staff on duty.

The people who used the service that we met during the visit were very positive about the home and the care provided. Comments included: "The staff really look after you" and "The staff know exactly how to help me." "It's a lovely place to live, the staff treat me well, I get lovely food and the situation is so peaceful, no need to complain." "I have all I need."

During our visit we spoke with eight people living at Ingham Old Hall as well as four staff members who worked there. We spoke briefly with one visiting vocational professional. We observed how people were treated and how staff interacted with them specifically during lunch time. We saw one person ask a member of staff for a blanket for their shoulders and this was brought to them immediately. We saw one member of staff asking people their choice of drinks and placed the drink within their reach before leaving.

We saw some people walking in different areas of the home, or sitting in two lounges, while others preferred to stay in their rooms. Staff were seen popping in to speak to people on their own and check they had things within reach.

We observed lunch being served and how staff helped those who required assistance with their food in a discreet manner. This sociable event was not rushed and people were given choices throughout. Two people commented: "The food is lovely. We have a good selection to choose from the menu." Another person told us: "Its good wholesome food, very tasty."

We looked at a selection of care records and checked the improvements made after the previous inspection.

People with whom we spoke told us that they were happy with the care they received. They said that staff treated them with respect and they felt safe and well cared for.

Some people told us that they were not always offered a choice of food but on the whole the meals were good.