You are here

Shenleybury House Limited Inadequate

We are carrying out a review of quality at Shenleybury House Limited. We will publish a report when our review is complete. Find out more about our inspection reports.


Inspection carried out on 10 March 2020

During a routine inspection

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

Rating at last inspection

The last rating for this service was Good (published 12 July 2018).

Why we

Inspection carried out on 14 June 2018

During a routine inspection

The inspection took place on 14 June 2018 and was unannounced. The inspection was undertaken by an inspector and an assistant inspector.

Shenleybury house is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. They are registered to provide accommodation and treatment for up to 15 people. At the time of our inspection 14 people were accommodated at the home.

At our last inspection on 30 June 2017, we rated the service Requires Improvement. At this inspection, we found evidence that improvements had been made in all areas and the service was rated Good overall. There was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 told us they felt safe at the service and there were appropriate risk management arrangements in place to help keep people safe. We observed people being supported safely. There was a robust recruitment process in place and sufficient staff members deployed to ensure that people’s needs were met in a timely way.

Staff received an induction to the service when their employment commenced and they continued to receive regular training and updates as required. Staff demonstrated they had the necessary skills and information they needed to support people safely and effectively.

People`s medicines were managed safely by staff who had received training and had their competencies checked. Care plans contained sufficient detailed information to enable staff to support people as they wished. People, where they were able, and or family were involved in the development and review of people's care plans.

People were asked for their consent before they were provided with support. Where people were unable to consent verbally, staff took time to get their consent through other means such as eye contact or body language. The management and staff worked in line with the Mental Capacity Act (MCA) principles and associated Deprivation of Liberty Safeguards DoLS.

People and their relatives told us staff were kind and caring and we observed staff supported people with compassion and clearly knew people well. Staff were aware of people`s likes, dislikes and preferences and delivered care and support in accordance to people`s wishes.

People were provided with opportunities to engage in social activities of interest to them. The environment and the grounds were well maintained and provided people with opportunities to utilise the surrounding outside areas. People’s bedrooms were personalised and people had their own furniture and soft furnishings as well as family photos and memorabilia.

The registered manager worked tirelessly to ensure people received good care in a homely environment. The management was open, transparent and inclusive and we observed visible and effective leadership within the service. The registered manager was supported by deputy manager who worked well as a team.

The management team provided people with a range of opportunities to provide feedback and comment upon the service; in order to continually make improvements. Records were being developed to make them more robust and consistent. They demonstrated a ‘people first’ approach and improvements required within records did not impact on the care people received. There was a comprehensive range of quality monitoring checks completed with an action plan in place to address any shortfalls.

Inspection carried out on 29 June 2017

During a routine inspection

The inspection took place on 29 and 30 June 2017 and was unannounced. The inspection was carried out by one inspector.

Shenleybury house provides accommodation for up to 15 people with residential care needs. It does not provide nursing care. At the time of this inspection there were 12 people living at Shenleybury house.

There was a manager in post who had registered with CQC. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 we last inspected the service on 12 August 2015 we found the provider was meeting the regulations. At this inspection although we found that the provider meeting the regulations, improvements were required to continue to meet the required standards.

People told us they felt safe living at Shenleybury house. Staff understood how to keep people safe and risks to people's safety and well-being were assessed and kept under review to help to keep them safe. People's medicines were managed safely, by staff who had received training. However we found some discrepancies in the medicine administration records (MAR) charts that had been completed.

People had their needs met in a timely way, by staff who demonstrated they knew people well. We observed there were adequate numbers of staff available to support people at all times.

Staff had received training and had the right skills and knowledge to support people safely. The recruitment process was not robust or consistent and this was an area that required improvement.

Staff were well supported and attended regular team meetings and individual one to one supervisions with their line managers. Staff told us they felt they were valued and listened to and worked well as a team.

People were supported to eat and drink sufficient amounts to maintain their health and wellbeing and were offered a choice of foods. People had access to a range of healthcare professionals when required to help maintain their health.

People, their relatives and staff were positive about the management at the service. We observed staff to be kind and caring and knowledgeable about people’s individual requirements in relation to their care and support needs and preferences. People were asked for their consent and they or their relatives where appropriate had been involved in the planning and review of their care.

People were supported to participate in activities that were provided. There were arrangements in place to receive feedback from people who used the service and their relatives. People were confident they would be listened to if they raised any concerns.

Systems were in place to monitor some aspects of the service and to check that people were happy with the quality of the care and support they received. However this was an area that required improvements as the systems that were in place did not identify some of the shortfalls we identified as part of our inspection.

Inspection carried out on 12 August 2015

During a routine inspection

This inspection was carried out on 12 August 2015 was unannounced. Shenleybury house provides care for up to fifteen adults over 65 years. It does not provide nursing care. The location had not had a registered manager for three months. However a new manager had been employed at the service and had only been in post 10 days at the time of the inspection and they were in the process of registering with the Care Quality Commission. 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 and associated Regulations about how the service is run.

On the day of our inspection, there were 11 people living at the home. The people being supported by the service had varying abilities and physical fragility associated with old age. The manager told us they had put a self-imposed restriction on new admissions until they were satisfied all aspects of the service had been reviewed and the service provided was of a good standard and was safe.

The Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection no applications had been made to the local authority in relation to people who lived at the service. The manager told us this was planned for during the next six weeks. Staff were fully aware of their role in relation to MCA and DoLS and how to support people so not to place them at risk of being deprived of their liberty.

The newly appointed manager told us that they were “virtually starting from scratch” in terms of all processes and documentation at the service as there were not many processes in place and many documents were not available when they came to work at Shenleybury House. This included documentation relating to people who used the service such as detailed care plans and current risk assessments. Likewise staff documents were under review, including recruitment, training, and supervision records as ‘historic’ and previous documentation were not available.

People received care that was personalised and staff knew them well. Relationships between people who lived at Shenleybury House, and support staff were positive. We found that staff were caring and responsive. People told us they were very happy living at Shenleybury House and that staff were very supportive.

The provider had an effective recruitment process in place that protected the people who used the service. Many of the staff had worked at Shenleybury House for many years and people had been supported by a consistent group of staff who they had been able to develop meaningful relationships with. However in recent months there had been an increase in the use of agency staff and people who used the service were not happy with all the changes which they described as ‘unsettling’. Recruitment was being addressed by the manager at the time of our inspection.

People were supported to maintain their health. They could visit their GP when required. The community mental health team also supported the people living at Shenleybury House.

Inspection carried out on 20 February 2014

During an inspection looking at part of the service

During our last inspection on 29 November 2013, we found that the provider was not meeting Regulation 23 of the Health and Social care Act 2008 because staff did not received formal supervision. This meant that they may not have had an opportunity to discuss work related issues with their manager.

During this inspection, we reviewed the supervision records, appraisals and training provided for staff. We spoke with people who use the service, staff members and one family member. One person said "I like the staff, they feel like friends. The staff speak to me with respect and call me by my preferred name". Another person said "Staff are fine, they meet my needs and I am perfectly happy". A family member said "I am happy because my mum is happy". Staff told us "They felt supported in their work, they had received appraisals and formal supervision�. Another member of staff said "I am having some training organised for me, this has happened through the supervision I received".

Inspection carried out on 29 November 2013

During a routine inspection

We observed that people who lived at Shenleybury appeared happy and contented in their surroundings. People we spoke with told us it was a lovely place to live and one person said �it�s the next best thing to your own home, small and personal.� We observed staff interacting positively with people who used the service and noted they knew people very well. During our visit we spoke with two people who lived at Shenleybury house, and we spoke to a visitor. All the people we spoke with were complimentary about the care and support they received. We noted from the review of records that people had been asked to consent to care and treatment, care plans and risk assessments were in place. We checked that the provider had a robust system in place for the administration of medication. We noted that staff support was irregular and needed improvements to meet the required standard. We were shown the complaints policy and procedure and found that complaints were recorded and investigated appropriately. We observed people relaxing in the lounge areas and people told us they had been assisting with the decorations the evening before which they had enjoyed.

Inspection carried out on 10 January 2013

During a routine inspection

People who lived at Shenleybury house told us it was like home from home and they would not like to live anywhere else. They said the staff were really caring and nothing was too much trouble. During our visit we spoke with three people who lived at Shenleybury house as well as talking to a visiting relative. People were positive about their support and one person told us that they were able to continue to live their live as they wished and staff did not make them do anything they did not want to do. A relative told us the staff were �lovely� and that although, over a period of time there had been minor issues their relative had certainly thrived since coming to live at Shenleybury. One person who had only just moved in said it was a lovely environment. We observed people joining in with activities and people said they felt like part of a family. We noted that people had access to a range of social activities.

People told us that they enjoyed their meals which were cooked freshly daily and were offered choices. Suitable arrangements were in place to assess people�s nutritional needs and ensure they received the food and fluids they needed.

There were robust recruitment procedures in place and staff received regular training.

We observed that people were living in a fresh, clean environment. People had their own furniture and personal items such as pictures in their rooms. All rooms had ensuite facilities and some had baths depending on people's assessed needs.

Reports under our old system of regulation (including those from before CQC was created)