Shirelodge Nursing Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant people’s needs were not always met.

This service scored 50 (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 make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

It was evident throughout the assessment that staff at all levels were committed to providing person-centred care. We observed a number of positive interactions between staff and people using the service, which demonstrated kindness and a genuine desire to support people. For example, one staff member told us, “Caring for people living at Shirelodge is our top priority.”

However, we found that oversight and governance arrangements had impacted the provider’s ability to ensure that person-centred care was delivered consistently across the service. While staff demonstrated a caring approach, practices were not always aligned with person-centred principles.

We identified examples of language used by staff that was not always respectful or person centred. For example, people were referred to as, “Feeds,” and terms such as, “Good girl,” were used when speaking to people. Such language did not promote dignity and individuality and risked undermining a culture that places people at the centre of their care and support.

Most people had been supported to personalise their bedrooms with items that reflected their interests, preferences and personal histories. However, this was not consistent across the service, and some rooms lacked personalisation.

There were some shortfalls in how the provider understood the diverse health and care needs of people.

The service provided care and support to people living with dementia. However, we found that not all areas of the home were designed or adapted in a way that effectively met the needs of people living with dementia. Opportunities to create a more dementia-friendly environment that promoted orientation, independence and meaningful engagement had not been fully explored.

During the assessment, we observed limited opportunities for stimulation and engagement, particularly for people living with dementia. Some communal areas lacked features, activities and points of interest that would encourage interaction, support reminiscence or provide meaningful occupation. The environment did not always feel welcoming, engaging or sufficiently tailored to the needs of people living with dementia.

We also found personal protective equipment (PPE) stored and readily accessible in a number of areas across the home. We were concerned that this presented a potential risk to some people, particularly those living with dementia who may be at increased risk of confusion or ingestion of non-food items.

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The provider had a range of information available to people, relatives and visitors, including policies, procedures and regular newsletters.

We found the provider's most recently reviewed Statement of Purpose was displayed within the reception area. However, the updated version had not been submitted to CQC.

We found opportunities had been missed to provide information through environmental cues and dementia-friendly design. The environment did not consistently support orientation, engagement and understanding, particularly for people living with dementia. For example, signage throughout the home was limited and did not always support people to independently navigate the environment or identify key areas of the service.

Photographs displayed on bedroom doors were not always of a sufficient size or quality to effectively support people living with dementia or visual impairments to recognise and identify their rooms independently. This meant opportunities to promote independence, orientation and a sense of familiarity had not been fully maximised.

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

The provider had a complaints policy in place. We reviewed the complaints records and found that two complaints had been received since November 2025. One complaint related to a delay in accessing care, and the other concerned a medicines error. We found that the responses provided did not fully address all of the concerns raised by the complainants. This was discussed with the nominated individual, who acknowledged that the responses had not comprehensively addressed all points raised.

The provider also undertook regular satisfaction surveys. We reviewed the 2025 people and relatives survey and found that, although many aspects of the feedback were positive, there was no accompanying action plan to demonstrate how areas identified for improvement would be addressed. The nominated individual informed us that a new survey was currently being collated and provided evidence of this during the assessment.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

Records reviewed during the assessment demonstrated that people were supported to attend routine healthcare appointments and access external health services when required.

The provider made use of some assistive technology to support people’s safety and independence, including falls sensors. However, opportunities had not been fully explored to maximise the use of technology to deliver care in the least restrictive way. For example, consideration could be given to the use of door sensors as an alternative to door guards, where appropriate, to promote people's freedom of movement while maintaining safety.

The provider had an on-call system in place, and the registered manager told us that a member of the management team was available 24 hours a day to provide advice and support when required.

The provider also had a business continuity plan in place. However, conversations with staff indicated that the plan was not fully embedded in practice. During the assessment, two members of staff were asked to review the business continuity plan and explain the impact that may result in the plan being implemented. Neither staff member was able to identify when the plan should be initiated, and both advised they had not participated in any business continuity exercises or contingency planning scenarios to test their understanding and response.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

People were supported by caring staff and we observed them to be comfortable in their home environment. However, the provider had not always considered how aspects of the environment and service delivery could impact people's experiences and outcomes.

For example, we found a bedroom was located adjacent to the kitchen. The provider had not fully considered the impact that noise and cooking smells associated with kitchen activities could have on the person occupying the room, nor had they adequately assessed any potential risks associated with its location.

The service had accessible outdoor space available for people to enjoy. However, we observed limited evidence of people accessing the grounds during the assessment. This was also reflected in feedback from relatives, who told us that opportunities to use the outdoor space were not consistently promoted. One relative said, "They have a lovely garden and as far as I am aware, they don't even take them out there."

People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

People had end of life care plans in place. However, these plans were not always sufficiently personalised and, in some cases, contained generic information that was not reflective of the individual's needs.

For example, end of life care plans referred to people experiencing breathlessness and other changes associated with the end of life. However, not all the people whose records we reviewed experienced breathlessness.