Shangri-La Residential Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question Good. At this inspection the rating has changed to Requires improvement. This meant the systems and processes in place were not effective to identify, embed or drive improvement across the service. The service was in breach of legal regulation in relation to governance at the service.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff said they felt able to speak up and were encouraged to do so. One staff member said, “Teamwork is key. Everyone works together and the [management team] ask for our opinion.” The registered manager said, “As an example, after day one of the inspection, we had a reflection with staff so that they felt involved.” When concerns were identified, these had been addressed through staff supervision and shared with staff through team meetings.

All staff were required to complete an induction and attend regular training, although we did identify some gaps in the training matrix. Some of the training was face to face. Records did not show staff had received regular supervisions, but staff told us they felt well supported in their roles. Regular staff meetings took place.

There was a fun and happy atmosphere observed at the home. We saw people were comfortable, relaxed and supported to remain independent.

There was a clear staff structure. Staff knew each other’s roles and responsibilities. The registered manager told us they supported staff and encouraged them to develop their skills and experience. We saw this as some staff had been given ‘champion roles.’ Everyone we spoke with, people, their relatives and staff expressed how supportive the registered manager and deputy manager were. If there were any concerns and support was needed, they were always a phone call away and would come in day or night depending on the support required. People’s relatives said, “The managers are [registered manager name and deputy manager name]; we know them both” and “They’ve got a very stable management at Shangri La and a lot of the staff have been there for years too.” One person’s relative said, “I like the monthly newsletter they send out which shows the planned entertainments for the next month; it makes you feel involved.”

The provider fostered a culture where people felt they could speak up and their voice would be heard. The registered manager said, “The staff here are very open and honest and they’re not afraid to challenge me.” The provider had a policy in place for staff to follow, however contact details for relevant agencies such as the local authority were not included. We saw this information was available to staff on the office board and there was a list of contact names for leaders in the service.

Staff told us they were well supported by senior staff, and the management team. The registered manager told us they had an open-door policy. A staff member said, “I feel supported in my role. [Registered manager] is very supportive and approachable.” Flexible working was considered for staff based on their individual needs and circumstances.

The service employed a diverse workforce. The registered manager said, “We want to know about the lives of our overseas staff, so we encourage all staff to chat and get to know each other. Our trainer is also helping us to develop some cultural training. We recognise that some aspects of care might be different for our overseas staff.”

The processes and procedures in place promoted staff equality and inclusion.

The provider failed to operate effective systems and processes to assess, monitor and improve the quality and safety of the service, and to ensure compliance with the requirements of the regulations. Systems for reviewing the quality and safety of the service failed to identify multiple shortfalls we found at this inspection. This included significant shortfalls around processes in place for consent, mental capacity assessments and best interest decision making for people where their memory or cognition was affected by a condition, such as dementia. Systems in place failed to ensure each service user had an accurate, complete, and contemporaneous record, including a record of all the care and treatment provided to the service users. This included records for repositioning, fluid monitoring, and behaviour management plans. We found inconsistencies in people’s medicines records, PRN (when required) medicines records and processes for managing homely remedies, topical creams and medicines storage was not always managed in-line with national guidance. Audits carried out failed to identify our concerns or drive improvement to mitigate risks related to the environment. This included window restrictors and actions taken in response to identified fire safety actions from the provider’s risk assessment. The provider failed to operate effective safeguarding systems to ensure all relevant information was shared with required organisations. Processes to monitor staff training and competencies were not effective. Staff training data was not always captured to reflect the training staff had undertaken and we found shortfalls across staff’s training records in areas that were relevant to their role. The provider’s overarching governance systems failed to demonstrate how organisational learning was shared and embedded across services to drive improvement in people’s experience of care.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People were supported to access the community, for example during activities with staff or family members. The service ran regular open days, and the deputy manager said, “Our open days are really successful. It’s good to get the local community in to see what we do.”

External professionals visited the home to meet the needs of people. Care reviews took place regularly with the input of relevant partners. We received positive feedback from health professionals we spoke with.

The registered manager was aware of where some improvements were needed, and some action plans were in place; however, the plans for the current year did not include all the areas we had identified, and the plans from the previous year did not show that any improvements had been embedded. Limited audits across the service meant it was difficult to assess how the provider assured themselves that actions and improvements had taken place.

Staff told us they were asked and involved with how the home was run. Regular staff meetings took place; however, the tone of the minutes of these meetings we looked at did not demonstrate a learning culture was promoted and did not always evidence that staff were encouraged to provide person centred rather than task focussed care.