About the service Shenleybury House Limited is a residential care home providing accommodation and personal care to seven people at the time of the inspection. The service can support up to 15 people.
People’s experience of using this service and what we found
The quality of care had deteriorated since the last inspection.
People’s welfare and safety was placed at risk due to inadequate safety measures in place. This included fire risk assessment and risk assessments that related to the environment. Individual risk assessments for people were ineffective and were not person centred. They failed to provide robust guidance for staff on how individual risks to people could be minimised. Actions which had been identified had not been completed.
The environment was poorly maintained, and many areas of the service were unclean. Equipment was found to be dirty and poorly maintained. This exposed people to the risk of infection and failed to protect their health and welfare.
Medicines were not managed safely, and audits completed were ineffective in identifying issues and concerns found during our inspection. People were exposed to the risk of harm from unsafe practice, due to inaccurate stock levels and a lack of staff training.
Staff were not recruited safely, and robust checks were not completed before staff started working at the service. There was no current training programme in place for staff. No records had been maintained to confirm that staff had received the necessary training to carry out their role effectively and safely. There was also no evidence to confirm that staff’s future training needs had been assessed or identified.
Staff had not been provided with regular supervision. The registered manager had not been provided with supervision since April 2019 when they commenced the role.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service also failed to support this practice.
People were not involved in the planning of their care. Care plans took account of people’s needs but lacked detail with regards to people's preferences, choices and individuality. Care plans were inconsistent and did not always give clear instructions to staff on how best to support people.
Quality assurance processes were not robust and were found to be ineffective in improving and further developing the service. The provider and registered manager had not acted upon previous professional feedback relating to the safety and quality of care at the service and ensure compliance with the regulations.
The registered manager demonstrated a lack of knowledge with regards to the systems in place and the processes that should be followed to manage an effective and safe service which achieves good outcomes for people and provides quality care. The registered manager had not been provided with an induction when they first commenced their role in April 2019 and had not been offered the training, support or guidance they required to carry out their role effectively.
The provider had a lack of oversight of the service and the nominated individual at the time of the inspection was not fulfilling the role. A nominated individual is responsible for supervising the management of the service on behalf of the provider. The provider took action to address this following our inspection.
People told us they felt safe at the service and were happy with the care they received. People were supported to make choices in relation to their food and drink and received support from health and medical professionals when required. Staff were seen to be kind, caring and committed to the people they were supporting.
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 Good (published 12 July 2018).
Why we inspected
The inspection was prompted in part due to concerns received about medicines management, staffing, the management of the service and a lack of provider oversight. A decision was made for us to inspect and examine those risks.
We have found evidence that the provider needs to make improvements.
Enforcement
We have identified breaches in relation to staffing, medicine management, risk management, infection control, premises and equipment and the overall management and governance of the service at this inspection.
We are mindful of the impact of 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.
You can see what action we have asked the provider to take at the end of this full report.
Follow up
We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Special Measures
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.