11 March 2015
During a routine inspection
This inspection took place on 11 March 2015 and was unannounced.
The Shrubbery is registered to provide accommodation for persons who require nursing or personal care. This service provides care for people over the age of 65 for long term, short term, convalescence, respite and holiday stays. The service has 45 registered beds, at the time of our inspection 44 of these were occupied and the remaining bed was unused as it was in double room which had single occupancy.
The service had 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.
We found that people felt safe and were protected from abuse. Staff were aware of safeguarding procedures in the event that abuse occurred and suitable recording and reporting systems were in place.
Risks were managed and staff had an understanding of general and specific risks posed to the service and people who used it.
Staffing levels were sufficient to meet people’s needs and staff had been effectively recruited following safe recruitment procedures.
People’s medicines were managed and administered safely by trained staff.
Staff received appropriate training and support to allow them to perform their roles.
Staff asked for people’s consent and the service had procedures in place to comply with the requirements of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards. However, there was not always evidence to demonstrate how some decisions had been made or how people had been supported to make a decision.
People had sufficient to eat and drink and could choose what they wanted to eat or drink.
People were supported to access healthcare services both in the service and local community.
There were positive relationships between people who used the service, their relatives and members of staff. People were treated with kindness and compassion and were listened to by staff.
People were supported and encouraged to express their opinions regarding their care and had a number of different ways to raise concerns.
People’s privacy and dignity was promoted and respected by members of staff.
Care was personalised and responsive to people’s needs. People and their relatives were involved in on-going reviews of their care plans and were supported to take part in meaningful activities.
The service had systems in place to seek feedback from people. This feedback was analysed and used to drive further improvements to people’s care.
There was a positive culture at the service. People were aware of their roles and responsibilities and there was a clear vision which everybody worked.
There was effective leadership and support in place. People knew who the registered manager was and were positive about the effect they had on the service.
We found systems were in place to monitor and improve the quality of care delivery.