Shenstone Court Care 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.

This is the first assessment for this service. This key question has been rated 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 the ways people’s medicines were managed safely.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The provider had some systems to learn from incidents and share learning, but these were not consistently effective. Staff described clear processes for escalating changes in people's health and medicines, including the use of handovers, flash meetings and multidisciplinary team notes. Staff told us they completed medicines training and competency assessments and felt able to raise concerns.

A staff member explained, “If I'd been off for a week, I could set the system for that week and read all the handovers."

A staff member told us, “If I've ever raised (a concern), I feel listened to.”

However, repeated delays in obtaining prescribed medicines demonstrated learning had not always been embedded effectively. The service had introduced additional competency assessments and increased medicines oversight in response to incidents, but inspection findings showed medicines-related concerns continued to occur.

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 generally supported through effective systems which enabled staff to recognise and respond to changes in health needs. Staff worked closely with external health professionals and care records contained detailed risk assessments, monitoring arrangements and escalation processes.

A professional told us staff, “Know the residents well and report deteriorating patients appropriately,” and were “Very good at managing weight loss.”

One relative described how staff responded to concerns promptly saying, “Staff raised concerns and found (medical condition) which was able to be treated quickly."

Another relative told us, “The home has communicated with us over health, medications and food."

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.

Staff understood how to raise concerns and described a culture where people could speak up when they identified potential risks. Staff told us they felt supported by managers and confident concerns would be acted upon.

People were supported in line with the Mental Capacity Act. We saw examples of capacity assessments, best-interest decision making and care planning which balanced safety, dignity and choice.

Staff were able to explain how they would assess capacity, involve relatives and attorneys where appropriate, and support people to make decisions wherever possible.

Where restrictions were in place or being considered, records showed the provider had considered mental capacity and Deprivation of Liberty Safeguards (DoLS). For example, one person had a DoLS application submitted and a mental capacity care plan was in place to guide staff.

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.

People were involved in decisions about managing risks whilst maintaining their independence and preferences. Risk assessments were in place for areas such as falls, choking, bed rails and behaviour that may challenge.

Care plans reflected individual choices and preferences, including decisions regarding personal care and support arrangements. However, some care plans contained inconsistencies and did not always provide sufficient information regarding prescribed medicines, allergies and medical diagnosis.

Staff described supporting people to make day-to-day choices, including clothing preferences and routines, while reducing identified risks.

A relative described how staff enabled a person to continue activities outside the care home which were important to them saying, “The registered manager altered the rota so [staff member] could go. Not a murmur of inconvenience."

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

The home was clean, well maintained and environment-related risks were routinely monitored. Maintenance systems, health and safety records, fire safety checks and equipment oversight were in place.

During the inspection we observed clean communal areas and personalised surroundings. People were seen moving safely around the home and interacting positively with staff.

People told us they felt comfortable within the environment and inspection observations found communal areas were clean, well-used and personalised.

Where concerns regarding equipment were identified during the inspection, these were reported immediately and management arranged for checks and replacements.

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.

Staffing arrangements generally enabled people to receive care and support, and managers actively reviewed staffing levels in response to feedback and dependency levels. The registered manager described increasing staffing above assessed levels when experience showed additional support was needed. Dependency tools were utilised to manage and respond to the growing needs of the home. One relative said, “Enough staff now, not before." Another relative told us, “They have more staff now."

However, some people and professionals continued to report delays at busy times. One person told us, “It would be better with more carers because sometimes you have to wait too long to have something done."

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 understood how to respond to wounds, skin integrity concerns and changing health needs. Staff described obtaining timely professional advice, making referrals and following prescribed treatment plans.

The home was visibly clean throughout the inspection and people appeared well cared for. Communal areas, lounges and bedrooms observed were clean and tidy.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medicines were not always managed safely. We identified stock discrepancies, medicines remaining in medicine trolleys after being discontinued, and concerns with medicines fridge monitoring. We identified delays in people obtaining prescribed medicines. For example, one person experienced a delay in accessing an antibiotic, which increased the risk of treatment not being provided in a timely manner. Care plans did not always clearly direct staff to medicines information. Relevant information, including allergies and prescribed medicines were not always recorded consistently across care records and information for medicines was not always clear to locate. Person-centred guidance for administering PRN (as needed) medicines was inconsistent, with rationale and outcomes not always assessed or recorded. The providers governance processes had failed to identify or address these issues, increasing the risk of people not receiving their medicines safely and as intended.