Sholden Hall Residential Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There had been improvements since our last assessment, but some further improvements were required. Previously staff had not always adhered to strategies to reduce risk, details of accidents and incidents were not always recorded, and the provider did not have clear oversight of accidents or incidents. At this assessment, staff had recorded incidents and accidents when they happened, and these were reviewed monthly by the provider to check the action taken. However, there was no evidence that accidents and incidents had been analysed to identify patterns and trends such as time of day or staff who were on duty. Staff had recorded incidents when they happened and the manager had taken immediate action. For example, a person had knocked their temple on the corner of a cupboard, while in the bathroom, causing a cut. The manager had moved the cupboard so this could not happen again.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The manager and staff told us how they had improved their pre-admission assessment process. The manager told us, previously assessments had been completed over the telephone, and a clear picture of people’s needs had not always been gathered. The manager now went to see people to assess their needs, they took a member of staff to make sure staff were confident they could support the person. Staff confirmed this was the new process, they were pleased they were being involved and their input was valued.

Staff had access to Information to send with people when they attended hospital or health appointments.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Following our last assessment, we raised concerns with the local safeguarding team which had not been identified by the registered manager or provider. The people involved had moved from the service and any continued occurrence of the concerns had been mitigated.The new manager had been in post since December 2025. They understood their role in identifying and reporting concerns and were completing safeguarding training for managers. The manager told us there had been no safeguarding concerns since they started at the service.Staff could describe the signs they would look for to indicate if someone was experiencing abuse and were confident to report these concerns to the manager or outside agencies.

The service had made Deprivation of Liberty (DoLS) applications to the local authority to deprive some people of their liberty. This is a necessary legal procedure to follow when a person who lacks capacity to consent to their care and treatment requires restrictions in order to keep them safe from harm.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.Following our last assessment, improvements had been made to people’s care plans and involving people to manage risks. The manager told us they had identified staff who had an interest in care planning and were happy to be the lead in writing them. People’s care plans had been re-written; they were person centred and detailed. Potential risks to people’s health and welfare had been identified and there was detailed guidance in place for staff to mitigate the risk.

Previously we had raised concerns about the management of people’s blood sugar and staff not having detailed guidance. At this assessment, the person’s care plan contained detailed guidance about the signs of high and low blood sugar and the action to take. Staff had recorded the person’s blood sugars and following a review of their medication, these had remained within the person’s target range.

Risk assessments had been completed for all areas of people’s lives, including leaving the building and emotional support. People’s risk assessments were detailed, we observed staff responding to people’s emotional needs as described in the care plan, and people appeared to be reassured. There was clear guidance about the amount of fluid people should aim to drink and this had been recorded, when needed, in people’s care plans. The care plans we reviewed showed people had been meeting their fluid targets.

Staff told us, they had been given responsibility to update people’s care plans and given time to involve people or their relatives in this process. During our onsite assessment we observed staff talking to people and relatives about people’s care plans. Some care plans we reviewed had evidence people had been involved in writing the care plans.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.At our last assessment, we identified shortfalls in the condition of the environment. At this assessment we found there continued to be concerns about the condition of some areas of the building. The issues identified at our last assessment such as loose tiles around the fireplace had been rectified. However, we found people’s rooms had not always been maintained, for example, a room had ceramic tiles falling off the wall, some fell off while inspectors were in the room. Following our onsite assessment, the manager sent a photograph of the area, and a new washable panel had replaced the tiles. Some of the rooms had broken tiles, poor quality flooring and damaged radiator covers. The manager told us they were identifying issues around the service, and the provider had been supportive and progressed the work.

At the last assessment, there were concerns about all aspects of fire safety, we raised our concerns with the local fire service. Following their visit, the provider had completed all the required actions to make the service compliant. Staff had now completed regular fire drills; these had been filmed so there was a visual record. Inspectors viewed the film, staff had followed the evacuation plan and people had been involved. There was a member of staff responsible for completing regular fire checks and these were up to date.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

At our last assessment, staff had not been recruited safely. At this assessment, the manager had reviewed all staff files to make sure there was a full employment history and any gaps in employment were explained. The manager understood how to recruit staff safely, however, no new staff have been employed since they started in the role. but there continued to be some minor shortfalls in relation to staff supervision.

Previously there were not enough staff to support people’s safety and risk mitigation strategies. At this assessment, some people who had required additional supervision and support had moved from the service. There were now some empty beds at the service and people’s needs had changed. The manager had calculated staffing levels using a dependency tool and made sure the staffing levels met the dependency tool. There was now an extra member of staff in the service at night to support with the fire evacuation plan. Staff told us, there were enough staff to support the people living at the service, and they were now able to support people’s needs safely. Relatives told us there were enough staff presently, comments included, “When we go, we always see plenty of staff. There is always someone at hand to take a resident to the toilet”. The manager told us they would review staffing levels when new people were admitted to the service according to their needs.

Previously, we had identified people were being restrained by staff who had not received appropriate training to make sure this was done safely. Though people were now not being restrained, staff had completed restraint awareness training. Staff confirmed they were aware of their responsibility to try to de-escalate people’s distress, only using restraint when it has been agreed and as a last resort. The manager had started to complete staff competency assessments, to make sure staff were following their training. However, we did find that staff supervisions had not taken place regularly. The manager had started to complete supervisions with staff but had not completed all of them.Following the assessment the provider confirmed all staff had received a supervision to discuss their practice.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. At our last assessment, not all the areas within were clean including ‘high touch’ areas which could increase the risk of the spread of infection. There were some areas which required deep cleaning and removal of limescale. At this assessment there had been some improvements but there continued to be some minor shortfalls. The service appeared to be clean including the ‘high touch’ areas, we observed domestic staff cleaning the communal areas including the bathrooms.

However, we found the furniture in some people’s rooms were not in good repair. For example, we observed bedside cabinets and overbed tables, where the washable covering was peeling away. Staff would not be able to wipe clean the surfaces to make sure they were clean. Some of the mattresses and chairs were fabric and were stained. The manager told us this had been identified in the audit they had completed and there was a programme to replace them all.Following the assessment the provider told us they had replaced the cabinets and tables identified in the assessment.The decoration in some areas of the service made it difficult for staff to keep clean including chipped tiles.

There were posters around the building reminding staff to wear personal protective equipment (PPE) including gloves and aprons. There were clear instructions for how to put them on and take them off safely. We observed staff wearing PPE appropriately and they told us there was always supplies available.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.At our last assessment we found medicines were not managed safely. During this assessment we found there had been improvements but there continued to be some minor shortfalls.There was now a senior carer with the responsibility to manage the medicines system. They showed a good understanding of how the system worked to make sure people had a constant supply of medicines. We checked the number of medicines available matched the computer records, we found a discrepancy, when the number of tablets had not been recorded in the system correctly. The number of tablets available was correct and the person had received their medicine as prescribed.

There are some medicines which require additional storage and 2 staff to sign a register to confirm they had been given. The records had not been completed when people left the service for a period of time. For example, medicines should be signed out of the register when given to the person or relative to take home and the record updated if any are not given when they come back. However, staff had continued to sign the register each night as if they were giving the person the medicine, which was not accurate. Staff had not followed guidance when supplying other medicines for people to take home, medicines should not be removed from the original packaging until they are taken by the person. Staff had dispensed the tablets into containers for each time the medicines were due, which did not follow best practice guidance. We discussed our findings with the manager and senior carer who told us they would make changes immediately. Following our onsite assessment, we received confirmation the changes had been made.