Shenstone Court Care 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.

This is the first assessment for this service. This key question has been rated Requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to governance at the service.

We have not awarded this service a score for Well-led.

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

The provider had a shared vision, strategy and culture that focused on supporting people to achieve positive outcomes. Staff spoke positively about the service and demonstrated a good understanding of people's needs, preferences and routines. Observations throughout the inspection showed caring, respectful and person-centred interactions, and people, relatives and professionals generally described the service positively. The registered manager promoted an open culture and worked alongside staff to address issues and improve people's experiences.

Not all leaders demonstrated effective oversight of the service. Whilst the registered manager was visible, approachable and supportive, leadership did not always ensure risks relating to medicines management were effectively monitored and addressed. Relatives consistently described the registered manager as approachable and willing to act when concerns were identified. During the assessment, the manager demonstrated understanding of many aspects of the service and implemented improvements when issues were identified. Staff felt supported in their roles and spoke positively about leadership within the home. However, leaders had not maintained effective oversight of medicines management and had failed to prevent the reoccurrence of omitted significant medicines. They had also not acted effectively to monitor and address concerns relating to antibiotic use, despite this being a known risk.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider promoted a culture where staff, people and relatives could raise concerns and feedback. Staff told us they felt comfortable speaking up and believed managers would listen and take action when issues were raised. People and relatives were able to discuss concerns with staff and management, and examples were provided where feedback had resulted in changes being made. The inspection process itself was open and transparent, with staff and managers engaging positively throughout.

The provider supported an inclusive culture where staff felt respected and valued. Leaders recognised individual needs and demonstrated consideration of equality and diversity, including supporting protected characteristics and making person-centred adjustments for people and staff. Staff described positive support and development opportunities, including progression into senior roles. The service also took steps to support internationally recruited staff through welcome information and induction arrangements.

The provider did not always have effective governance systems to consistently identify, assess and mitigate risks. Although audit systems, management monitoring arrangements, daily walkarounds and oversight processes were in place, these had not identified the medicines management concerns, recording discrepancies and governance issues found during the assessment.

As a result, quality assurance systems did not provide effective oversight of the service and failed to ensure safe care and treatment was consistently delivered. Leaders had not identified or addressed all areas of concern before our assessment, which meant risks were not always recognised or responded to in a timely way.

Governance systems and processes were ineffective in assessing, monitoring and mitigating risks to people’s safety. Although the provider had audits, daily oversight, walkarounds and management monitoring arrangements in place, these systems had failed to identify significant concerns found during the assessment in relation to medicines management, medicines-related records and wider governance oversight.

This represented wider weaknesses in oversight and assurance, rather than isolated shortfalls. Leaders had not recognised the extent of the risks before our assessment and the provider could not demonstrate that its quality assurance systems gave reliable oversight of whether safe care and treatment was being delivered consistently.

The registered manager was open and responsive when concerns were raised and took immediate action, including investigations, additional audits, competency reviews and strengthened medicines monitoring. However, these actions were reactive to our findings and did not reduce the seriousness of the governance failures. At the time of assessment, there was insufficient evidence that improvements were embedded, effective or sustainable.

The provider worked effectively with external professionals and community services to support people's health and wellbeing. Staff demonstrated a good understanding of referral and escalation processes and worked closely with GPs, district nurses, nurse practitioners and other healthcare professionals. People also had access to community opportunities, activities and outings that helped reduce social isolation and maintain wellbeing. External professional feedback confirmed staff generally communicated concerns appropriately and recognised changes in people's health needs

The provider demonstrated some commitment to learning and improvement and had taken action in response to identified concerns. Staff described how learning was shared through handovers, flash meetings, competency assessments and training. Leaders reviewed incidents, accidents and trends and used this information to identify areas requiring improvement.

Following concerns relating to medicines management, the service had introduced additional measures including an antibiotic tracker, medicines workshops and increased oversight arrangements. Leaders told us learning was shared with other homes within the organisation and governance processes had been reviewed where gaps had been identified.

However, the assessment identified ongoing concerns in relation to medicines management and governance oversight. While the provider had recognised these issues and was taking steps to address them, the impact of these improvements could not yet be fully demonstrated. This meant the provider was able to evidence some learning and improvement activities, but not a consistently effective approach to continuous improvement across all areas of the service.