Shangri-La 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 inspection we rated this key question requires improvement. At this assessment the rating has changed to good: This meant people were safe and protected from avoidable harm.

At our last inspection the provider was in breach of legal regulations in relation to safe care and treatment, medicines management, safeguarding and contemporaneous record keeping.

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

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff meeting minutes showed the management team were promoting a learning culture within the service. For example, a meeting held in January 2026 focused on learning from incidents, particularly falls. This included using a case scenario to encourage reflection about the importance of accurate record keeping and clarifying expectations around the post-fall protocol. These subjects were revisited at a subsequent staff meeting in April 2026 to ensure learning was being embedded. Staff we spoke with told us they felt managers promoted a positive learning culture.

A new accident / incident log with learning outcomes was in use including monthly summaries to monitor any trends. This was being introduced to strengthen management oversight and document operational learning. The provider also used a monthly governance, operational and risk report to monitor the quality and safety of the service.

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.

People were supported to attend healthcare appointments. Staff either accompanied individuals or arranged appropriate support, ensuring attendance and continuity of care.

Staff told us they worked well with health and social care professionals and had developed good working relationships. This was further confirmed by feedback we received from health professionals, including for example, “Overall, my experience of working with Shangri-La Residential Home has been positive, andI feel residentsgenerally receiveappropriate supportwith their health and wellbeing.”

There were clear processes to ensure people’s current information was safely shared with health and social care professionals. Records showed people were reviewed by health professionals when required. This included, for example, the district nurse team, the older people’s mental health team, the optician and the speech and language therapist team (SALT).

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.

People confirmed they felt safe living in the home. Their comments included: “It’s very good. Everyone is for you” and “The staff are good and they’re aware of situations and security. It’s comfortable and quite homely.”

Feedback from external professionals confirmed the provider continued to work with them and had an action plan to monitor and share safeguarding concerns.

The safeguarding policy and procedure had been reviewed and updated in March 2026, to ensure it refers to the local authorities’ procedures and detailed clearly who is responsible and accountable for managing safeguarding concerns within the home.

The new home manager spoke clearly and confidently about their responsibilities in relation to safeguarding procedures. The deputy manager showed us records of weekly safeguarding audits that were being used to provide a full overview of safeguarding incidents and investigations. Records included details of what and who to report incidents and outcomes to.

Staff knew how to report safeguarding concerns and were aware of outside agencies they could contact if necessary. Staff could describe possible signs of abuse and were confident that the management team would respond appropriately if they raised any concerns.

Where people were subject to Deprivation of Liberty Safeguards (DoLS), staff knew how tosupport them as people’s care plans contained information and guidance. DoLS applications were made appropriately. There were no conditions attached to people’s current DoLS authorisations.

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.

The provider had an updated falls management policy including a post falls protocol. Staff confirmed they were issued with a flow chart version of the protocol and demonstrated knowledge of it. The accident and incident reporting policy and procedure had been reviewed and updated in March 2026 and contained clear and relevant information for staff.

Most of the records related to people’s risks were accurate and up to date to reflect their needs or the care provided, including position changes, behaviour support, and fluid charts. Some further work was ongoing to embed the new recording systems. For example, we noted some differences in the detailed information between computer and paper records. We did not find any evidence to suggest this was having an impact on people’s health and wellbeing, and the home manager was addressing these issues.

There were risk assessments and support plans for people who were communicating a need, expressing feelings or an emotional reaction. For example, one person was known to react to personal space intrusions. Records showed incidents were being managed appropriately. Staff were proactive in preventing escalation and in adapting the environment and routines to minimize risks. The person’s health and wellbeing were closely monitored, with regular input from external professionals.

Staff received training and demonstrated understanding of individual’s needs and how to manage situations that could potentially cause people to become anxious.

Two individuals were reported to lock their doors when out of their rooms. One person could request staff assistance to unlock the door when they wished to access their room. The other person could not request assistance; this was recorded within their mental capacity documentation. The person’s care records clearly stated the door was not used to isolate or restrict them. Where doors were locked from the outside, individuals could still exit independently using the internal handle. In the event of an emergency, each member of staff had a master key.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We observed the service was being refurbished as part of ongoing home improvements. The electrical re-wiring of the office had been completed as part of this. Following a recent inspection and recommendations by the fire and rescue service, the home manager had updated the fire safety policies and scheduled more fire evacuation drills for staff. The home manager was also working on people’s existing personal emergency evacuation plans (PEEPS) to ensure these remained consistent with the updated fire procedures.

We reviewed records of up-to-date checks that had been carried out. This included gas, electrical equipment and other fire safety checks. Regular checks of equipment were carried out. There was a current certificate of legionella testing.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Feedback from people and relatives was positive. Comments included, “They do their best to help you” and “They look after your every need.” People felt staff had time for them and did not rush their care. Staff told us they felt there were enough of them on duty to meet people’s needs. During the inspection, call bells were responded to in a timely manner and staff did not appear rushed.

The provider used a dependency calculator tool to review the care hours required by each individual and staffing levels available to provide these. The current registered manager explained that staffing levels had been increased due to monitoring trends, particularly at night. They reported that analysis had identified some people spent significant amounts of time awake overnight so required more support.

Records showed and staff confirmed they received relevant training; competency checks and supervision. During the inspection we observed a group of staff receiving training in moving and repositioning, and tissue viability. Staff told us training was now being done in smaller groups and in shorter sessions, which they felt worked better. Staff supervision records demonstrated that staff were provided with appropriate support and guidance.

We reviewed the recruitment records of 2 recently employed staff. The records were mostly complete, including full Disclosure and Barring Service (DBS) checks and employment histories. There was one missing previous employment reference in relation to one new member of staff. The reference had been requested initially, and a follow up request was made on 13/04/26. The home manager was in the process of making another request and recording a risk assessment on the staff file while awaiting a response.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff had been trained in infection prevention and control and were supplied with personal protective equipment (PPE) such as gloves and aprons. There were effective processes to prevent and control infection. Staff knew how to manage infection outbreaks at the service. Cleaning schedules were followed and records showed rooms and equipment were cleaned regularly. Hand gel dispensers and PPE stations were in place around the home.

There were audits in place to oversee the cleanliness and safety of the environment, and the service was visibly clean and tidy. Food safety was maintained and kitchen monitoring checks were adhered to. There was an ongoing programme of replacing furniture, some of which was worn and could therefore pose a risk of cross contamination.

Feedback from people and their relatives described the service as clean and well maintained. Comments included: “They clean it every morning. It’s always spotless and occasionally they have a deep clean” and “I went into the garden on Monday, and they did a thorough clean and watered my plants for me.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People’s medicines were managed so that they received them safely. There were procedures and records in place and staff demonstrated knowledge and understanding of the processes. Records showed people’s medicines were kept under review and they received them as prescribed by their GP. Two members of staff checked and signed when medicines were administered or disposed of.

Some people were prescribed additional medicines on an as required (PRN) basis. PRN protocols were person centred and gave clear guidance for staff to follow before and after giving PRN medicines. For example, the protocol for a person prescribed medicines for agitation and anxiety informed staff of steps to take to relieve those symptoms before resorting to the use of medicines. Records were also completed an hour after administration to reflect why the medicines were given and the outcome. The home manager informed us staff had recently received training focused on PRN outcomes, which we saw were being audited.

The medicines storage room was clean and air conditioned, and the temperature of the room and medicines fridge were monitored. Creams and lotions prescribed for people were safely stored and dated when opened, which meant staff would know when the contents had expired.

We saw a range of medicines audits demonstrating the service had a safe approach to medicines management, with evidence of compliance across key areas including storage, administration, record keeping and stock control.