Inglefield Nursing & Residential Home

“Our assessment identified a number of significant concerns affecting the safety and quality of care. At the last inspection, the service was rated good. At this assessment the service remains good overall. However, the provider was in breach of regulations in relation to safe care and treatment and good governance.”

“Medicines management was inconsistent. Some medicines were stored outside recommended conditions, including fridge temperature issues and use of liquid medicines past their in-use expiry date. Care plans and ‘as required’ (PRN) protocols were not consistently individualised, limiting assurance that people received consistent safe and personalised treatment.”

“Risk assessments and care planning contained inaccuracies and contradictions. Records sometimes misrepresented people’s needs, including support with personal care, constipation management, and prescribed medicines. Monitoring tools, including Abbey Pain Scale assessments and National Early Warning Score 2 (NEWS2) observations, were not always used effectively to guide care, reducing confidence that changes in people’s health were consistently identified and acted upon.”

“Consent processes were not fully robust. Closed-Circuit Television (CCTV) use lacked explicit consent, and some forms were completed on behalf of people with dexterity difficulties without clear verification. Environmental and risk management systems required strengthening; while the service was generally clean and well-maintained, some risks were not consistently identified or mitigated.”

“Governance and leadership were supportive and focused on improvement, but oversight processes were not always fully effective. Audits, supervision, and learning initiatives were in place, yet gaps in follow-through meant some risks were not identified and actions were incomplete, reducing assurance that care consistently met regulatory standards.”

“People received kind, compassionate, and person-centred care, and staff worked effectively with healthcare partners to promote wellbeing and maintain independence. Positive relationships with relatives and staff engagement supported a warm and inclusive culture.”

“We have asked the provider for an action plan in response to the concerns found at this assessment.”