1 August 2018
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection was unannounced on the first day and took place on the 16 and 18 May 2018. The inspection team consisted of two inspectors and an expert by experience on the first day. The second day one inspector completed the inspection. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Before the inspection the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what it does well and any improvements they plan to make. We reviewed notifications and any other information we had received since the last inspection. A notification is information about important events which the service is required to send us by law. In addition, we requested feedback from local authority commissioning with experience of the service. We received this information prior to our inspection.
We spoke with the registered manager, the deputy manager, the activity coordinator,12 members of the care team, one visiting GP and maintenance and reception staff. We spoke with twenty-one people who used the service and seven visiting relatives.
We reviewed 13 care records, medication charts on each floor, documentation in relation to quality assurance records and other records relating to the way the service was run.
We observed practice throughout the service and used a Short Observational Framework for Inspecting (SOFI). SOFI is a way of observing care to help us understand the experience of people who were unable to communicate with us.
1 August 2018
This inspection took place on the 16 and 18 May 2018 and was unannounced on the first day.
During the most recent inspection of Shelburne Lodge in March 2017 we found breaches of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014. This was because we found management of people’s medicines were not effective. The provider had failed to maintain accurate records in respect of people using the service. Sufficient numbers of staff were not deployed to meet the needs of people using the service.
Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions in safe, responsive and well led to at least good.
During this inspection we found the provider had made improvements and was now meeting the regulations.
Shelburne Lodge 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.
Shelburne Lodge accommodates 54 people in one adapted building. At the time of our inspection there were 45 people using the service, 21 on the ground floor and 24 on the upper floor.
The service requires a registered manager to manage the service. At the time of our inspection a registered manager was 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.
We received mixed views from people we spoke with about the service. Comments included, "I use my buzzer, they don't always come quickly", “Yes I use my buzzer; if you want a shower you can have one, you feel safe, they know how to do it”, “Yes I have three pills a day and it all goes well”. Relatives told us, “My [family member] gets on well with the carers", “I hear call bells going off and they seem to answer them very quickly”, “On the whole they are alright, weekends are usually alright”, “I’ve never regretted [family member] being here”.
Safeguarding adults’ procedures were in place and staff understood how to protect people from the risk of abuse.
The service had safe recruitment procedures in place to ensure only suitable staff were appointed. Sufficient staff were available to meet people’s needs.
Risk assessments were not always completed according to identified risks. Staff sought people’s consent and involved them in the care planning process where possible.
People received their medicines as the prescriber intended. Audits were in place to monitor the administration of people’s medicines.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; policies and systems in the service supported this practice.
The service ensued people had access to healthcare professionals when required. The GPs involved in the service carried out routine visits and advice was sought from other professionals when required.
The service had a complaints procedure which was available for people and their families to use as necessary.
Audits were carried out to monitor the quality of the service provided.