Ingham Old Hall Care Home

Ingham Old Hall Care Home is a residential home that provides personal care to up to 25 older people, some of whom may be living with dementia. It is a converted period building with extensive gardens. At the time of the inspection, Ingham Old Hall was home to 23 people. Although the home is registered for up to 25 people, 2 rooms are not being used meaning the home was at full capacity.

People’s experience of using this service and what we found

People told us their needs were met in a person-centred and timely manner by staff who were well-trained, kind, compassionate and caring. They 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.

People’s needs had been assessed and accurate, person-centred care plans were in place that had been regularly reviewed. The risks to people had been identified and measures were in place to reduce them. Healthcare needs had been considered and met. People received food of their choice, in appropriate quantities and that they enjoyed. Medicines were well managed, administered safely and in line with best practice.

Good infection prevention and control measures were in place and COVID-19 had been well-managed, considered and mitigated. We saw that the home was visibly clean, and people had a choice of how they spent their day. Their rooms were personalised, and signage was in place to assist orientation.

Complaints were taken seriously and investigated and people we spoke with told us they felt listened to and involved. Staff told us they felt supported and that teamwork was effective. There was an open culture within the home and people were encouraged to speak up. Feedback on the service had been sought and the provider had worked with experts to improve the quality of the service.

People told us that improvements had been made in the service since our last inspection and this was observed and corroborated. A new registered manager had been appointed who had a good oversight of the service, had implemented action plans to address concerns and had a robust governance system in place to monitor and assess the service and continue to drive improvement. Whilst further embedding was required, we had confidence that the service would continue to improve.

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

Rating at last inspection (and update)

The last rating for this service was requires improvement (report published on 28 November 2019) and there were two breaches of regulation; a warning notice was served in relation to medicines management. The provider completed an action plan after the last inspection to show what they would do and by when to improve. As this inspection we found improvements had been made and the provider was no longer in breach of regulations and had been compliant with the warning notice.

Why we inspected

Prior to the inspection we carried out a monitoring review of the service. A monitoring review considers a range of information such as the current rating, any ongoing or planned regulatory activities, information about safeguarding, whistleblowing, incident reports (we call these statutory notifications), whether the service has a registered manager, feedback from people who use services and their family and friends, and other contextual information. This prompted us to carry out this inspection as evidence suggested the service had improved.

We undertook this focused inspection to check the provider now met legal requirements and where we had evidence that the service had improved from their previous rating of requires improvement. This report only covers our findings in relation to the key questions of safe, effective, responsive and well-led.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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.

Follow up

We will continue to monitor information we receive about the service and take action as appropriate.

Ingham Old Hall is a residential care home providing personal care. At the time of the inspection, care was being provided to 18 people aged 65 and over who live with dementia. The service can support up to 25 people. Accommodation is over two floors of an adapted period building.

We found the following examples of good practice.

• The manager has sent monthly emails to families with photos of their relative to help reassure and give updates

• A gazebo had been erected in the garden to enable visiting of family members. This was by appointment only, with two visits per day so that the area can be disinfected between visits. Visitors were having their temperature taken and handwashing was required prior to appropriate Personal protective Equipment (PPE) being supplied

• Additional safety measures were put in place to facilitate socially distanced visits for a relative to see their family member indoors due to a specific identified need.

• Cleaning staff had been increased to ensure that enhanced levels of cleanliness were maintained with cleaning schedules and checklists being robust

• Staffing levels had been increased during the pandemic to provide extra support and social activities.

• Isolation procedures put in place when a person living in the home tested positive for COVID-19 had worked, so the virus did not spread within the home.

• COVID-19 care plans had been completed for all residents which included a section identifying if the person understood the measures required to keep them safe.

Further information is in the detailed findings below.

Ingham Old Hall is a residential care home providing personal and nursing care. At the time of the inspection, care was being provided to 12 people aged 65 and over who live with dementia. The service can support up to 25 people. Accommodation is over two floors of an adapted period building.

People’s experience of using this service and what we found

Although the provider had made some improvements since our last inspection, we continued to have concerns about their ability to provide a consistently safe and high-quality service. Progress had been slow in making improvements and continued concerns were found at this inspection. Our concerns were increased as issues were ongoing even though there were a low number of people living at Ingham Old Hall.

Previous enforcement had been taken at this service which had resulted in conditions being placed on the provider’s registration. This meant focussed action plans were to be submitted to CQC each month to demonstrate what actions the provider planned to take to drive improvement. These had been submitted as required but had failed to consistently cover the areas of concern as specified in our enforcement action.

Risks had not been consistently identified and mitigated and this put people at risk of harm. For example, a fire escape had not been identified as a potential risk and the risks associated with people choking had not been regularly reviewed. Medicines management was unsafe and did not follow good practice guidance. People had not consistently received their medicines as prescribed and, for one person who used the service, this had resulted in an increase in their symptoms associated with a medical condition. The audits the service had in place to assess risks and medicines management had failed to identify and rectify the concerns found.

Improvements had been made to the environment since our last inspection and refurbishment continued. This had benefitted those living at Ingham Old Hall although the age and structure of the building limited people’s ability to easily orientate around the home. However, we found the home visibly clean throughout with no malodours. People’s rooms were personalised to their taste and preferences.

People received person-centred care in most aspects of their lives although improvements were required in how the service meets people’s individual leisure needs. Care plans were individualised, full of person-centre detail and accurate. They had been regularly reviewed and people and their relatives had been involved in their development. 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.

People told us their needs were met by staff who were kind, knowledgeable and well trained. They spoke positively about the staff’s abilities and had confidence in them. People were treated with respect and their dignity maintained which made them feel valued. Staff spoke respectfully about the people they supported and knew them well having after having developed meaningful relationships with them.

Systems in place ensured staff were recruited safely and the training and support they received meant they had the skills to perform their roles. They demonstrated an increase in knowledge since our last inspection and morale and team work had improved. They told us they felt well supported by a registered manager who was approachable and available.

People’s nutritional and healthcare needs were met, and the service worked in partnership with other professionals to ensure appropriate care was delivered. People were protected from the risk of abuse and infection as the systems in place reduced these risks. A complaints policy was in place although most people did not feel the need to raise any concerns. Where people had raised concerns, they told us the service was responsive and proactive.

We received positive feedback from people who used the service and their relatives. People told us they were happy living at Ingham Old Hall and with the care provided. They acknowledged the recent improvements at the service and explained how this had positively impacted on them. One relative explained how the service was much more vigilant now whilst another attributed the improvements to the approach and hard work of the registered manager. Staff agreed that the service had improved and told us the positive impact this had had on those people that used the service.

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

Rating at last inspection (and update)

The last rating for this service was Inadequate (report published on 21 August 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. The provider was also submitting monthly action plans in response to conditions applied to their registration following a previous inspection. Although some improvements were noted at this inspection, enough had not been made and the provider was still in breach of regulations

This service has been in Special Measures since November 2018. During this inspection the provider demonstrated that some improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures. Conditions imposed on the provider’s registration in November 2018 will be removed due to the improvements made.

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ingham Old Hall on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to safe care and treatment and governance at this inspection. Please see the action we have told the provider to take at the end of this report.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

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 tasks was received within the stipulated timescales. The action plan indicated completion of all urgent risks and issues would be by the end of July 2018. We will continue to monitor progress made against this action plan and any regulatory action as an outcome of this full inspection report.

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.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

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.

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 to maintenance checks. Accidents and incidents were recorded and managed appropriately. An overview was in place to help mitigate future risk.

People liaised with staff over the planning of their care although this was not always evident from the care plans we viewed. Care plans were individual to people and had been regularly reviewed. The content varied between care plans but staff had a good knowledge of the needs and preferences of those they supported and had developed meaningful relationships.

The service provided activities and social interactions that people enjoyed. Activities were not always planned but we saw a number of informal, dedicated activities take place with people that were individual to their needs and wishes.

People had appropriate and prompt access to healthcare and community professionals were complimentary on how the service managed these needs. People’s nutritional needs were met and people who required specialist diets received this. Consideration was given to how those living with dementia could better maintain their nutritional wellbeing.

Feedback was sought on the service via meetings and questionnaires. Systems were in place to assess and monitor the quality of the service although these were mostly carried out on an informal basis.

People told us they saw the management team regularly and that they were accessible and visible. The provider’s representative made regular visits to the service, provided support and engaged with those who used the service, visitors and staff.

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.

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.

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."

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.