The Care Quality Commission
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Archived: The Shrubbery Rest Home

Overall: Good read more about inspection ratings

126 Wood Road, Codsall, Wolverhampton, West Midlands, WV8 1DW (01902) 844871

Provided and run by:
The Shrubbery Rest Home

Important: The provider of this service changed. See new profile

All Inspections

To Be Confirmed

During a routine inspection

We inspected this service on 26 November 2015. This was an unannounced inspection. Our last inspection took place in March 2014 and we found no concerns with the areas we looked at.

The service was registered to provide accommodation for up to 26 people. At the time of our inspection, 21 people were using the service.

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.

When people were unable to consent mental capacity assessments and best interest decisions were not completed. The provider had not considered that some people were being restricted and that deprivation of liberty safeguards referrals were needed.

People told us they felt safe and staff demonstrated they knew how to recognise and report potential abuse. The provider had procedures in place to report concerns. Equipment was checked and maintained to ensure that it was safe to use.

People told us medicines were managed in a safe way. There were effective systems in place to administer; store and record medicines to ensure people were protected from the associated risks. We saw there were enough staff to meet people’s needs.

People could access sufficient amounts of food and drinks and when people had specialist diets they were catered for. People were referred to health professionals for support when needed.

People were treated in a kind and caring way and their privacy and dignity was promoted by staff. They were able to make choices about their day and participated in hobbies and pastimes they enjoyed. People and families were involved with reviewing their care and staff received training to offer support. People were supported to maintain relationships with friends and family and they could visit the service.

Quality monitoring checks were completed by the provider and this information was used to bring about changes to the service when needed. The provider sought the opinion of the people and relatives who used the service and used this to make improvements. Staff felt they were listened to and were given the opportunity to raise concerns. People knew who the manager was and felt they could approach her if needed. There was a complaints procedure in place and people knew how to complain.

We found 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.

10 March 2014

During an inspection looking at part of the service

We completed this inspection to check that the provider had made the improvements needed following our last inspection in June 2013. When we visited last time we found that people's views and experiences were not taken into account in the way the service was provided and delivered in relation to their care. There were also concerns about staff training and the lack of systems in place to monitor the quality of the service provided. The provider sent us an action plan telling us how they would improve the service.

At this inspection we saw that improvements had been made. There were meetings enabling people who used the service to have a say in the way the service was provided. We saw improvements in staff training and a number of audits and checks had been completed to ensure the quality of the service was maintained.

24 June 2013

During a routine inspection

We carried out this visit to check on the care and welfare of people using this service. The visit was unannounced which meant the provider and the staff did not know we were coming.

26 people were in residence when we visited. We spoke with eleven people living in the home, two visitors, four staff and two health professionals.

Some people who used the service were unable to speak with us either because of frailty or personal preference.

We found that people who used the service were not involved in decisions about the way in which the service was provided.

We saw that care records provided sufficient information to staff about how to meet the needs of the people who used the service.

We found that staff did not receive sufficient training to meet the needs of the people who used the service.

We found that there were not effective systems in place to assess and monitor the quality of the service provided.

During a check to make sure that the improvements required had been made

We visited the service to undertake a scheduled inspection on 12 July 2012. We found minor concerns regarding outcome 4 Care and Welfare of people who use services. This was in relation to poor risk assessments that needed more specific recorded information and action to be taken to minimise the risks for the people using the service. Care plans also needed more specific recorded information about the person, and for some information held to be archived. Involvement by the Local Authority in regard to concerns raised resulted in enquiries being made and a satisfactory outcome. We also liaised with the Local Authority in relation to a person's care that needed to be reviewed. We received satisfactory feedback from them in relation to this.

We found minor concerns in relation to outcome 16 Assessing and Monitoring the Quality of Service Provision. Audits of the service were not being routinely undertaken, and lessons learnt were not recorded or reflected in feedback in order to improve the service. There were no documented audits by the provider, although we were told that these were taking place. Individual Fire risk assessments were not up to date. We subsequently received a satisfactory action plan and evidence that the provider had undertaken their audit, this information included confirmation of actions taken in relation to our findings.

12 July 2012

During an inspection in response to concerns

We visited the service to check on the care and welfare of people who were living at The Shrubbery Rest Home. The visit was unannounced and neither the home nor the provider knew that we would be visiting.

During our visit we used different methods to help us understand the experiences of people using the service. We spoke with people living at the home, a visiting health professional, visitors, staff members, the manager and the provider, and we spent time observing the care provided in the home.

We spoke to nine people living at the home and three visiting relatives. People we spoke with were all positive about the care and support that they or their relative received. One person told us, "it's alright here" and another said, "the staff are very pleasant, even when they are very busy". People told us that staffs were kind and caring. They told us that staff assisted them when they needed it. One relative said, "I have no problems at all with the staff, they are very good at what they do'.

We found that the home was comfortable and that people were able to personalise their bedrooms as they chose to, to reflect their own taste and interests.

People were consulted about their care. People told us how they spent their day. They said that they got up and retired to bed when they choose. They told us about the activities that had taken place, including how much they used to enjoy the games, and also about their jubilee celebrations. The home was in the process of recruiting an activities person.

Care plan records did not include all the relevant information to ensure that care was delivered appropriately and in a consistent way.

We spoke with a member of the district nurse team who confirmed that care staff at the home always cooperated with any instructions that were required.

We found minor concerns in relation to individual risk assessments. These were not comprehensively and clearly documented, and did not provide more detailed information for care staff on actions that were needed to minimise risks to people.

We saw that staff were fully aware of the safeguarding policies and procedures to follow, and that appropriate systems were in place to minimise the risk of harm to people.

We found minor concerns in relation to the quality assurance of the service. We saw that audits of the service were not taking place, and there was very little feedback from the surveys undertaken by the home.