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 good. At this inspection 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. The provider was in breach of legal regulation in relation to safe care and treatment, medicines management, safeguarding and contemporaneous record keeping.

This service scored 53 (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 and did not always share information about safety events with relevant organisations such as CQC or the local authority. There were ineffective systems and processes in place and leaders failed to demonstrate organisational learning was shared and embedded across services. There were ineffective processes in place to monitor and review accidents and incidents at the service. For example, patterns and themes across the service were not always identified and actions had not always been taken to embed learning. Team meetings were used to inform staff of changes; however, meeting records did not always demonstrate there was a positive learning culture promoted by leaders, or that they had considered how to drive improvement where repeated issues were highlighted at 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. People and their relatives said the service supported them to attend external appointments such as hospital appointments. People told us they had access to GP services.

Staff told us they worked well with health and social care professionals and had developed good working relationships. We spoke with a health professional who worked with the service. They said they had a good relationship with the staff. They said, “The staff here keep us updated. They will ring us before we arrive and tell us about any residents they want us to review. They are very proactive” and “I know one person from when they were living in their own home. Since [they] have lived here, they are well nourished, clean and generally better.”

There were clear processes to ensure people’s current information was safely shared with health and social care professionals. Staff told us they had virtual ward rounds with the GP and could access additional advice and support from the GP surgery if needed. Records showed people were reviewed by health professionals when required. For example, records showed people were reviewed by the district nurse team, the older people’s mental health team, the optician and the speech and language therapist team (SALT) if staff noted swallowing concerns.

The provider did not share concerns quickly and appropriately. We found significant shortfalls in the providers safeguarding processes. We reviewed accidents and incident analysis records for October, November and December 2024 and found leaders consistently failed to share relevant information of concern where legally required with the local authority safeguarding teams. Although the provider completed some internal investigations, they failed to meet their legal requirements to report all required information and leaders demonstrated a lack of understanding on their requirements for reportable information. The providers policy for safeguarding was not robust. The policy did not provide relevant information for staff on the key legislation to safeguard people or ensure staff had clear information on who, how and what they should report to meet their requirements. The provider submitted most of the applications where people were deprived of their liberty, however we found 1 example where a person’s care plan indicated they could not provide informed consent for their care or accommodation and the provider had failed to follow the required process in line with their legal requirements. We were not assured staff fully understood how to uphold and promote people’s right to leave the service where they were not subject to any legal authorisation to restrict people’s liberty. For example, we spoke with staff about people who were not identified to have any legal restrictions in place and actions they would take if they wanted to leave. Staff told us they would intervene to prevent people leaving as they felt this kept them safe.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Potential risks to people’s health and welfare had been assessed and risk assessments had been reviewed regularly. However, records related to people’s risks were not always accurate or up to date to reflect their needs or the care provided. For example, we looked at records for one person who had been assessed as high risk of skin damage and had developed a pressure wound. Repositioning records informed staff to change the person’s position “2 hourly due to a sore.” Records we looked at for the week of the inspection, showed gaps in recording, sometimes for periods up to eight hours. Some staff had used the 24-hour clock to record when support was provided but some had not, so the timing of position changes was not always clear. This put people at increased risk in relation to their skin integrity breakdown. In 2 people’s care plan for potential aggression towards staff, the plan informed staff to use “Appropriate restraint” but did not specify what this was. This meant there was a risk that staff would be unclear how they should respond to an incident of physical aggression. People’s weight was monitored. When people had been assessed as being at risk of malnutrition, records showed staff had escalated concerns to the GP. However, it was unclear how staff knew about any fluid intake targets, and it was also not clear how concerns about poor fluid intake were noted and escalated.

Staff were aware of risks to people’s safety, for example, choking and skin damage. One staff member said, “[Name] is on thickener. If [they] start choking, I call for help straight away and slap them on the back. We would call 111 or the GP.” Another staff member said, “I feel we speak about risk a lot in handover, we talk about each resident. The management are happy for us to bring up any concerns.”

We received positive feedback from people and their relatives about the care they received, and no concerns were raised.

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.

The up-to-date electrical installation certificate was dated 26 September 2023, and the overall assessment of the installation was ‘Satisfactory’; however, there were areas for improvement recommended for action. The registered manager told us the previously booked remedial work had to be postponed but was rebooked for February 2025. This meant there was delay of nearly 17 months for the work to be carried out. The failure to undertake remedial work within a reasonable time frame meant there was a potential risk of harm to people. We also found some of the actions within the provider’s latest fire risk assessment dated September 2024 had not been actioned within the recommended time scales.

We reviewed records of checks carried out. This included gas, electrical equipment and other fire safety checks. Regular checks of equipment were carried out. We looked at personal evacuation plans (PEEPs); there were 3 people’s PEEPs missing from the file. The registered manager actioned this during our inspection. The PEEPs we saw had been regularly reviewed to reflect people’s support needs in the event of needing to evacuate the building in an emergency.

The provider did not always make sure staff received effective support, supervision and development. Processes to ensure staff were suitably trained and competent were not always effective. For example, we were not always assured that staff were receiving their supervisions or annual appraisals in line with the provider’s policy. Despite this, staff told us that they could speak to the manager if they needed to and that they would be listened to. We were not assured that all staff had completed training relevant to their role. The provider’s training records reflected gaps where some staff had not completed training in key areas, such as dysphagia, epilepsy and tissue viability. We reviewed 3 staff moving and handling competency records and found records were incomplete. This included ensuring dates observations were undertaken were consistently recorded and records did not demonstrate who had undertaken the observations as the signatory section was incomplete. Therefore, it was not clear how leaders ensured staff had the appropriate skills and knowledge in line with requirements.

People gave mixed feedback about staffing levels. Comments included, “Sometimes it seems to me that there are not enough staff around, but not all the time. I feel sorry for them really, they have so much to do but they are cheerful and helpful” and “There are times when they are noticeably busy, I think care workers generally get low wages, but they are a good bunch here.”

People’s relatives said, “Because some of the residents need a lot of staff to care for them, I sometimes think there could be more based in the lounge” and “Sometimes there’s not a member of staff in the lounge, if they have been called away. Sometimes there’s agency staff working there and I don’t think [agency staff] always know enough about my relative.”

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 assessed and managed the risk of infection.

At the time of the inspection, there was an infection outbreak within the service and three people were isolating in their bedrooms. This was being well managed with clear signage on doors and personal protective equipment (PPE) stations outside affected rooms.

Staff had attended training in infection prevention and control and through conversation demonstrated a good knowledge of how to prevent the spread of infection. Staff told us that because of the outbreak at the service, they were wearing masks, aprons and gloves when going into affected people’s bedrooms. This helped to minimise the risk of cross contamination.

In the main, the environment was visibly clean. However, some of the furniture and pressure cushions we looked at were worn and could pose a risk of cross contamination.

People’s relatives commented, “It’s clean and immaculate here; they are always cleaning and picking things up” and “There’s never any messy areas. Sometimes there’s a very slight smell but not often.”

Food safety was maintained. Kitchen monitoring checks were in place.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Controlled medicines were stored safely. However, best practice and the provider’s policy was not always followed in relation to record keeping. There were not always two staff signatures to show the stock balance had been checked by two members of staff when medicines were administered or disposed of. We saw 15 missing signatures on people’s medicine administration records. The service also used homely remedies; these are over the counter medicines which the GP approved the use of. There was no record of running stock balances in place which meant it was difficult to assess if stock balances were accurate or not. Some people were prescribed additional medicines on an as required (PRN) basis. The PRN protocols in place were not person centred and did not inform staff when and why people might require them. Protocols for people prescribed medicines for agitation or anxiety did not inform staff of steps to take to relieve those symptoms before resorting to the use of medicines. The temperature of the medicines storage room and fridge were monitored. However, the room temperature was recorded as 25.1 degrees at 10.44am and records showed the temperature of the room and medicines trolley had exceeded 25 degrees on 76 occasions in the previous six months. A pharmacist audit carried out in June 2024 recommended considering the use of air conditioning but there was nothing documented to show if this had been considered by the provider. The fridge where some medicines were stored was visibly dirty around the seals and needed to be defrosted. Creams and lotions prescribed for people had not been dated when opened, which meant staff would not know when the contents had expired. Additionally, we saw creams and lotions in communal bathrooms instead of being stored safely in people’s bedrooms.