Shirelodge Nursing Home

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

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. However, further work was needed to record Mental Capacity Assessments (MCA) and best interests’ decisions to ensure they follow good practice guidance.

Risks were managed, and people’s care plans detailed current risks and individual needs. Medicines were managed safely, and infection control measures were followed. During the COVID-19 pandemic safe visiting processes were followed to support people to maintain relationships with friends and relatives.

Staff were recruited safely and there were enough trained staff to meet people’s needs safely.

People and their relatives were involved in the planning and reviewing of their care. People were supported to maintain a balanced diet. People and their relatives were involved in planning their care. Care plans detailed people’s individual needs and preferences.

The quality monitoring processes and actions following incidents had improved. The registered manager and provider were proactive in implementing changes in order to improve the quality of care provided.

People using the service, relatives and staff commented the registered manager was approachable and making a positive difference to the quality of 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 requires improvement (report published 22 May 2021) and there were breaches of regulations 12 (Safe Care and Treatment) and 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities).

Following the last inspection, the provider was required to submit monthly action plans to show what they were doing to improve the service.

At this inspection we found enough improvement had been made and the provider was no longer in breach of the regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. The inspection was also prompted in part, due to risks identified for further follow up during our direct monitoring of the service. A decision was made for us to inspect and examine those risks.

We found no evidence during this inspection that people were at risk of harm from the areas identified.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions 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.

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

Follow up

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Shirelodge Nursing home provides accommodation, personal and nursing care for up to 54 older people, some of whom live with a dementia. At the time of the inspection, 43 people were living at the service.

People’s experience of using this service

There was a lack of oversight in monitoring and acting on risk and overall governance of the service. This had the potential to place people at risk of harm.

Accident and incident forms were not always completed following incidents. This impacted on the overall monitoring of people’s risks. Actions to reduce further risks were not identified.

In some areas of the home, the environment continued to be poor. This was identified at the previous inspection and an action plan was in place to address the concerns. However, timely action had not been taken by the provider to ensure furniture and fittings were fit for purpose.

Systems and processes required improvement to ensure information gained at the assessment stage was followed through when people moved in to the home.

The systems and processes in place to monitor the safety and quality of the service required strengthening. Concerns identified at this inspection had not been identified by the provider, however, they took immediate action to respond to the concerns raised.

Staff understood their roles and responsibilities to safeguard people from the risk of harm. People were mostly supported to access relevant health and social care professionals. People were protected from the spread of infection. Personal protective equipment such as gloves and aprons were readily available.

People received care from staff they knew and thought the staff were kind and caring. Staff had a good understanding of people's needs, choices and preferences. People were encouraged to make decisions about how their care was provided and their privacy and dignity were protected and promoted. Staff gained people's consent before providing personal care.

People and their relatives were involved in the planning of their care which was person centred and updated regularly. People were supported to express themselves, their views were acknowledged and acted upon. There was a complaints system in place and people were confident any complaints would be responded to appropriately.

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.

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

Rating at last inspection:

The last rating for this service was requires improvement (published 17 January 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to risks and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Shirelodge Nursing home provides accommodation, personal and nursing care for up to 54 older people, some of whom live with a dementia. At the time of the inspection, 33 people were living at the service.

We found the following examples of good practice.

¿ Safe arrangements were in place for professional visitors to the service. These included temperature checks, risk questionnaire, hand sanitisation and wearing a mask. Visitor plans were in place to support visits by relatives when it became safe to do so.

¿ There was plenty of personal protective equipment (PPE) including masks, gloves, aprons and hand sanitiser available. PPE stations were located around the corridors and nearby all of the rooms where people were isolating.

¿ All staff had been trained in current infection prevention and control (IPC) guidance and in the use of personal protective equipment (PPE). There were designated areas for donning and doffing of PPE and handwashing facilities were easily accessible to people and staff. We observed staff followed current guidance and practice throughout our visit.

¿ A regular programme of testing for COVID-19 was in place for staff and people who lived in the service. The service were preparing to offer testing to relatives in the near future as part of the government roll out of this service.

¿ Enhanced cleaning took place throughout the environment on a daily basis. We observed the environment was clean and hygienic. Communal spaces were used creatively to ensure people could continue to interact with each other and staff in a safe way.

¿ The clinical lead was the designated IPC staff at the service and undertook regular audits to make sure staff complied with current guidance and practice. Any concerns picked up through these checks were acted on without delay.

¿ The service's IPC policy was up to date and in line with current guidance. The service had plans in place and knew how to respond to an outbreak of infection to ensure the safety of people and staff.

¿ People admitted to the service were supported following government guidance on managing new admissions during the COVID-19 pandemic. The provider had specific COVID-19 care plans in place for people to provide guidance for staff caring for them.

Further information is in the detailed findings below.

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

Shirelodge Nursing Home accommodates up to 54 older people in a purpose-built building. People were accommodated on the ground and first floor of the building. The service provided support to people requiring general nursing, residential care and people living with dementia and memory loss. At the time of our inspection there were 47 people living there.

The service had a registered manager. 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.

People did not always receive care that protected them from an act of control and restraint that was unnecessary and disproportionate.

People told us they felt safe, however there was a concern that incidents were not always reported to the registered manager when they were witnessed by staff.

People received their medicines when they required them, however staff who administered medicines had not had their competency assessed on a regular basis. Although staff felt supported, not all staff received regular formal supervision.

The environment required some refurbishment to ensure it was suitable to meet people’s needs and improvements were required in relation to the care planning documents being consistent across the service.

The systems and processes in place to assess, improve and monitor the safety of the service were not always effective. The provider did not have a policy in place that offered guidance on how often and in what circumstances staff should have a renewed Disclosure and Barring Service (DBS) check.

People’s needs were assessed prior to coming to the home and risks to people had been identified and measures put in place to mitigate any risk. There were sufficient staff to meet the needs of the people; staffing levels were kept under review.

People were involved in decisions about the way in which their care and support was provided. Staff understood the need to undertake specific assessments where people lacked capacity to consent to their care and / or their day to day routines. People’s health care and nutritional needs were carefully considered and relevant health care professionals were appropriately involved in people’s care.

People were cared for by staff who were respectful of their dignity and who demonstrated an understanding of each person’s needs. This was evident in the way staff spoke to people and the activities they engaged in with individuals. Relatives spoke positively about the care their relative received and felt that they could approach management and staff to discuss any issues or concerns they had.

The registered manager was approachable and people felt confident that any issues or concerns raised would be addressed and appropriate action taken.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.