Background to this inspection
Updated
18 March 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
Inspection team
This inspection was completed by one inspector and a nurse specialist. A nurse specialist has nursing knowledge to review these areas of the service.
Service and service type
Shipley Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We spoke with local commissioners and health care professionals and used all this information to plan our inspection.
During the inspection
We spoke with two people who used the service about their experience of the care provided. We spoke with eight members of staff including the provider, nurses, senior care workers, care workers, domestic staff and the chef.
We reviewed a range of records. This included four people’s care records, incident reports and multiple medication records.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and further quality assurance records. We requested three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
We also contacted four family members by telephone to obtain their view of the care their relative was receiving.
Updated
18 March 2022
About the service
Shipley Hall is a nursing and residential care home providing personal and nursing care to 18 people aged 65 and over at the time of the inspection. The service can support up to 30 people. Accommodation was provided in a traditional property across three floors, with communal areas.
People’s experience of using this service and what we found
There was limited governance and oversight of the service and the provider was not meeting the required condition on their registration for a registered manager. This impacted on the day to day management of the service and in regular auditing and quality checks.
Audits which were in place were not effective. Accidents and incidents were not always reviewed and thoroughly analysed to reduce the possibility of similar incidents reoccurring. Other audits provided the incorrect information meaning equipment was not replaced in a timely manner.
Risks associated with people's care and specific health conditions, for example Parkinson's or diabetes had not always been identified, mitigated and monitored.
Staff had not received the required training for their roles. There were times of the day when staff were not available to support people in a timely manner, this was because tasks were not allocated effectively.
Potential safeguarding concerns in the service had not been reported or responded to effectively.
Staff did not always feel listen to or supported in their roles. Seniors and nurses were required to manage the home along with completing their caring duties.
Relatives told us that staff were very caring, compassionate and knew people well.
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 good (published 14 December 2019).
Why we inspected
The inspection was prompted in part due to concerns received about governance and people’s levels of care. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Shipley Hall on our website at www.cqc.org.uk.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to risk management, staff training and management of the service at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.