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The Shelley Care Home Requires improvement


Inspection carried out on 24 November 2020

During an inspection looking at part of the service

About the service

The Shelley Care Home is a residential care home providing personal and nursing care to 28 people with a range of health and support needs, including Parkinson’s disease and people living with dementia. The service can support up to 32 people.

People’s experience of using this service and what we found

People’s risks were not fully assessed to protect them from the risk of avoidable harm. Some actions were taken where people were at risk of falls, but systems were not sufficiently robust to mitigate risks. Medicines prescribed for people living with Parkinson’s disease were not always administered in a timely manner. Infection prevention and control systems had been implemented and were effective.

Auditing systems had not identified all the issues found at this inspection and were not effective in driving improvement to the care people received. The system used to monitor accidents did not correspond with records relating to accidents and incidents, including falls, that people had sustained. A medicines audit did not include how medicines that were required to be refrigerated had been monitored. The majority of staff had not received Parkinson’s disease awareness training or in the management of falls which would enable them to support people's needs appropriately.

People were happy living at the home and felt safe. One person commented, “Yes I feel safe thank you. The staff are always courteous and kind. They are always here and if I need them I can call my bell”. People could attend residents’ meetings to share any concerns or to make suggestions about how the home was run. Staff told us they enjoyed working at the home and felt supported by management.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 Outstanding, (last report published 18 July 2018).

Why we inspected

This inspection was prompted due to information of concern received regarding infection control, staffing, and the management of the home. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well led only.

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 have found evidence that the provider needs to make improvements. Please see the Safe and Well Led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Outstanding to Requires Improvement. This is based on the findings at this inspection.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection carried out on 19 February 2018

During a routine inspection

The Shelley Care Home is a residential care home registered for up to 32 people with a variety of health and support needs. At the time of the inspection, 29 people were living at the home. Accommodation is provided over two floors and all rooms have en-suite facilities. Communal areas include a sitting room, dining room and garden room adjacent to landscaped, accessible gardens.

At our last inspection in September 2015 we rated the service Outstanding. At this inspection we found the evidence continued to support the rating of Outstanding and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Why the service is rated Outstanding.

Feedback provided by people living at the home included, “My impression is the staff are immensely well trained. I honestly couldn’t find fault with any member. They are always helpful and never drag their feet”, and, “The food is superb, really excellent. The dining room is quite spectacular too and has a lovely ambience”. People were extremely complimentary about the staff at the home and one person said, “The staff are very friendly and chatty. They are so gentle with me and treat me like one of the family”. People and their relatives were fully involved in all decisions relating to the care, including their wishes for their end of life care. As one person commented, “I’ve discussed end of life and my wishes have been written down and arrangements are already in place. I mentioned a wish that I had and they’re doing everything possible to try and locate someone for me; they give me progress reports all the time. They really do go above and beyond”. Staff were thought of highly by people and one person explained, “The managers are very good indeed. They couldn’t do more for you. The care is outstanding. Even the people who work here, who have worked at different homes, say how superior it is here”.

The home had built on their previous success and sustained the outstanding model of care and support provided to people. The home provided a safe environment and people were asked what would make them feel safe and then improvements were made. People’s independence was not compromised and risks were assessed to encourage people to do as much for themselves as they could. For example, many people managed their own medicines. People received continuity of care from regular staff and there was a culture of staff working closely together.

In addition to mandatory training, staff were encouraged to complete additional training to help them develop in their role. Staff discussed the training they had undertaken and reflected on their learning. Some staff were Champions in specific areas, and provided advice and support to other staff, which contributed to the high quality of care that people received. A range of healthcare professionals ensured people received holistic care which was delivered to an exceptionally high standard. People were overwhelmingly positive about the quality of the food on offer and enjoyed socialising with each other in the dining room. The environment of the home was relaxing and comfortable. Great thought had been given to the furnishings and the décor was of an exceptionally high standard. Staff were discreet in their attendance on people, but were kind, caring, thoughtful and warm in their approach. Excellent teamwork was an essential ingredient embedded in the service to ensure that people received continuity of care.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the home support this practice. Everyone living at The Shelley Care Home was deemed to have capacity and people were free to come and go as they pleased.


Inspection carried out on 11 September 2015

During a routine inspection

The inspection took place on 11 September 2015 and was unannounced.

The Shelley Care Home provides personal care and support for up to 32 older people who have a variety of health and support needs. At the time of our inspection, there were 30 people living at the home; the home also provides short breaks and respite to people. The Shelley Care Home is a substantial, detached Victorian building with a large two-storey extension at the rear. The original building is on two floors served by a four-person passenger lift. The front and rear gardens are well maintained, with lawn, flowerbeds and patio areas for people to enjoy. All rooms are single occupancy and have en-suite facilities. There is a spacious entrance hall, large dining room, sitting room and patio leading to the rear garden.

There was a registered manager in post. 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 felt safe living at the home and their risks had been identified and assessed so that staff were well informed on how to look after them safely. The philosophy of the home supported people to take greater control in their lives and to make choices. Staff had been trained to recognise the signs of potential abuse and knew what action to take. Staff understood the requirements under ‘duty of candour’ under health and social care legislation and were open and transparent with people who used the service. They were able to describe its relevant and application and put this into practice. Accidents and incidents were reported and dealt with satisfactorily. There were sufficient numbers of staff on duty to keep people safe and staff also had time to chat with people. Questionnaires were sent out to people to ascertain whether they felt there were sufficient staff. The service followed safe staff recruitment practices. People’s medicines were managed safely and people’s capacity to administer their own medicines was assessed.

Staff were well trained in a range of topics and also received specific training to meet people’s individual needs. They were supported and actively encouraged by management to take additional qualifications which supported their continual professional development. Staff ‘champions’ had been recruited who received additional training in a range of areas such as diabetes management and mental capacity; they provided support to other staff to ensure best practice was implemented. All staff underwent an induction period and went on to complete the Care Certificate, which is a universally recognised qualification. Staff understood the requirements of the Mental Capacity Act (MCA) 2005 and associated legislation under the Deprivation of Liberty Safeguards (DoLS) and put this into practice. Staff received regular supervisions and annual appraisals.

People’s nutrition and hydration needs were met exceptionally well so that people enjoyed eating and drinking and maintained a healthy lifestyle. Comments about the food and the mealtime experience were overwhelmingly positive. The standard and quality of the cuisine was exceptionally high and people could have a drink or something to eat at any time of the day or night. Special occasions, such as birthdays or anniversaries, were celebrated at the home. People’s day to day health needs were met and they had access to a range of professionals. In addition, a healthcare professional visited the home regularly. People could make an appointment with this person who provided extra health support and advice to promote their mental and physical wellbeing. When people moved to the home, their room was redecorated and completely refurbished in line with their personal preferences.

People were looked after by kind and caring staff who knew them exceptionally well. People and their relatives were all extremely positive about the care that was delivered and the warm, friendly attitude of all staff. Staff were sensitive, very empathic to people’s needs and were prompt to provide assistance when needed. The home showed concern for people’s wellbeing in a caring and meaningful way and offered additional services to people at no extra cost. Staff described ‘relationship-centred’ care as a way of including the person and their family and went the extra mile to care and comfort people. People were supported to express their views and be involved in all aspects of their care; their privacy and dignity were promoted.

People received care and support that was responsive to their needs. Care plans provided detailed information about people so staff knew exactly how they wished to be cared for in a personalised way. People were at the heart of the service and were cared for as individuals and encouraged to maintain their independence. A wide and varied range of activities was on offer for people to participate in if they wished. Outings were also organised outside of the home and people were encouraged to pursue their own interests and hobbies.

Complaints were listened to and dealt with to the complainants’ satisfaction within 28 days of receipt.

People were actively involved in developing the service and interviewed and met with new staff. Residents’ meetings were organised and, additionally, a Food Reflection Group had been set up where people solely discussed the food, drink and menu choices available. Their recommendations were listened to and acted upon. A monthly newsletter, website and Facebook page enabled people to stay in touch with their families and those that mattered to them. The home had a set of vision and values which was incorporated into the way the service was run and helped to deliver high quality care in line with people’s individual requirements. All feedback from people and their relatives was exceptionally positive and people spoke highly of the provider and the registered manager. There was a range of systems in place to audit and measure the quality of the care provided and service delivered. The home sought advice from a range of organisations to strive towards, and build on, best practice.

The vision and values of the service were focused on providing person-centred care and treatment and staff were attentive to the small things that made a big difference to people. Staff were led by the principles of kindness, empathy, dignity and respect. This was evident at all levels of the service, from the management to the care staff.

Inspection carried out on 7 November 2013

During a routine inspection

At the time of our inspection there were 29 people who lived in the home. We spoke with six people, relatives and to staff. People told us that they were involved in decision making regarding their care and treatment. They were encouraged to express their opinions, preferences and views. We found that people were treated with dignity and respect. People told us that they were involved in their care decisions.

We found that care was person centred, planned and delivered safely with regular reviews in order to ensure that care was appropriate to needs. People's care was planned and delivered according to their assessed needs and preferences. One person's relative told us that they felt that ' this was Rolls Royce care. Nothing was too much trouble and that the staff were wonderful and friendly'.

People told us that they felt safe in the home and that care workers understood their roles. We found that people were safeguarded against risk and abuse by knowledgeable, trained and committed care workers. People said that there were always enough staff available to meet their needs. Staff had received appropriate training and support in order to provide high quality person-centred care.

We found that the provider had effective systems in place to monitor and assess the quality of the service, which took into account the views of the people, relatives and staff. We saw that the provider used this feedback to make service improvements.

Inspection carried out on 31 January 2013

During a routine inspection

We spoke with five people who lived at The Shelley and one relative. All of the people we spoke with were highly satisfied with the care and support provided by the staff at The Shelley. People described it as "Luxury in Heaven," "There's nowhere like it," "Very Good," "Excellent" and "Absolutely first class." People said that staff and the manager were professional, respectful and helpful.

We found that people were treated with dignity and respect. People's individuality and choices were respected by staff on a daily basis. People told us they were involved in their care decisions.

People's support was planned and delivered in line with people's assessed needs and preferences. People and their relatives were involved in care planning. The manager regularly reviewed and updated people's care records to ensure they were accurate and fit for purpose.

People told us that The Shelley was a safe place to live and an environment where concerns and complaints could be raised. We found that people were safeguarded against the risk of abuse and neglect because staff understood how to identify and report concerns. The provider responded appropriately to complaints and safeguarding concerns.

Staff had received appropriate training and support to ensure they carried out their roles effectively. Members of staff felt supported in their roles.

Records were appropriately maintained and stored.