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Inspection Summary

Overall summary & rating


Updated 27 July 2017

We inspected Shipley Hall Nursing Home on 9 May 2017.This was an unannounced inspection. The service provided accommodation, nursing and personal care for up to 30 older people with a range of age related conditions including frailty and dementia. On the day of our inspection there were 24 people using the service, including one person who was in hospital.

Our last inspection took place on 24 & 27 May 2016. At that time there was no registered manager in place and we identified concerns relating to inadequate levels of infection control. This was a breach of Regulation 12 (Safe Care and Treatment) Health and Social Care Act 2008 (regulated activities) Regulations 2014. Following this inspection we asked the provider to send us an action plan detailing how they would address these issues. Following this the provider sent us their action plan telling us about the improvements they intended to make. During this inspection we looked at whether or not those improvements had been met. We found some improvements had been made regarding infection control procedures and the service was no longer in breach.

However we identified other concerns regarding the culture of the service, which was not always open and inclusive. We also found communication was inconsistent and staff did not always feel valued by the provider.

There was still no registered manager in post on the day 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.

People received care from staff who were appropriately trained and confident to meet their individual needs. They were supported to access health, social and medical care, as required.

People’s needs were assessed and their care plans provided staff with guidance about how they wanted their individual needs to be met. Care plans we looked at were centred on the individual and contained the necessary risk assessments. These were regularly reviewed and amended to ensure they reflected people’s changing support needs.

Policies and procedures were in place to help ensure people’s safety. Staff told us they had completed training in safe working practices. We saw staff supported people with patience, consideration and kindness and their privacy and dignity was respected.

People were protected from the risk of harm or abuse by thorough recruitment procedures. Appropriate pre-employment checks had been made to help protect people and ensure the suitability of staff who was employed.

People received their medicines in a timely way. Medicines were stored, administered safely by staff who had received the necessary training.

People’s nutritional needs were assessed and records were accurately maintained to help ensure people were protected from risks associated with eating and drinking. Where risks to people had been identified, these had been appropriately monitored and referrals made to relevant professionals.

Staff received training to make sure they knew how to protect people’s rights. The service acted in people’s best interests and maintained regular contact with social workers, health professionals, relatives and advocates.

There was a complaints process in place. People were encouraged and supported to express their views about their care and staff were responsive to their comments.

Inspection areas



Updated 27 July 2017

The service was safe.

There was sufficient staff on duty to safely meet people’s identified care and support needs. Medicines were stored and administered safely and accurate records were maintained. People were protected by thorough recruitment practices, which helped ensure their safety.



Updated 27 July 2017

The service was effective.

Staff were confident and competent in their roles. They had training in relation to the Mental Capacity Act (MCA) and had an understanding of Deprivation of Liberty Safeguards (DoLS). The service maintained close links to a number of visiting professionals and people were able to access external health care services.



Updated 27 July 2017

The service was caring.

People and their relatives spoke positively about the kind, understanding and compassionate attitude of care staff. Staff treated people with kindness, dignity and respect. People were involved in making decisions about their care; they were asked about their choices and individual preferences and these were reflected in the personalised care and support they received.



Updated 27 July 2017

The service was responsive.

Staff had a good understanding of people’s identified care and support needs. A complaints procedure was in place and people and their relatives felt confident any concerns or issues raised would be addressed.


Requires improvement

Updated 27 July 2017

The service was not always well led.

There was no registered manager in post. The quality of service provided was monitored but audits relating to the running of the service were inconsistent. The culture of the service was not always open and inclusive. Staff felt supported, although not always valued by the provider.