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Shenleybury House Limited Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 30 January 2021

About the service

Shenleybury House Limited is a residential care home providing accommodation and personal care to nine 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 interim manager and staff team had worked hard to address the issues found at our last inspection and to ensure people’s care and support needs were fully met. People’s care plans and associated risk assessments had been reviewed and checks undertaken to ensure that actions required were completed.

Safe recruitment processes were followed, and staffing levels were consistently maintained. Medicines were managed safely.

The service had implemented hygiene practices in accordance with national guidance relating to COVID-19. We saw staff were wearing Personal Protective Equipment (PPE) relevant to the tasks they were completing and demonstrating good hygiene practices. Improvements had been made to the cleanliness of the environment and a re-decoration and maintenance plan for further works was in place.

The interim manager had implemented quality monitoring process that reviewed all aspects of the service provided to people, however these required further time to fully embed. They demonstrated that lessons were learned to make improvements to the service where required.

Relatives gave positive feedback regarding the service and their experiences of the care provided.

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 Inadequate (published 22 August 2020).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations 12, 15, 17 and 19.

This service has been in Special Measures since 22 August 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

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 coronavirus and other infection outbreaks effectively.

We carried out an unannounced comprehensive inspection of this service on 10 March 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve risk and safety management, environment, infection prevention and control, staffing, nutrition and hydration, person centred care and governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-Led which contain requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Inadequate to Requires Improvement. 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 Shenleybury House Limited on our website at www.cqc.org.uk.

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.

Inspection areas

Safe

Requires improvement

Updated 30 January 2021

The service was not always safe.

Details are in our safe findings below.

Effective

Requires improvement

Updated 30 January 2021

Caring

Requires improvement

Updated 30 January 2021

Responsive

Requires improvement

Updated 30 January 2021

Well-led

Requires improvement

Updated 30 January 2021

The service was not always well-led.

Details are in our well-led findings below.