Shirelodge Nursing 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 assessment we rated this key question Good. At this assessment the rating has changed to Inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, staffing and safeguarding people from abuse and improper treatment

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider's systems and processes for recording, reporting and investigating incidents were ineffective. We found examples where incidents had either not been reported, had been reported late, or had not been adequately investigated.

The provider had implemented an electronic incident management system; however, this had not been embedded effectively within the service. Not all staff had appropriate access to the system to enable them to report incidents, and we found evidence that not all incidents had been recorded or reported in line with the provider's procedures.

The provider had not undertaken effective analysis of accidents and incidents beyond falls to identify themes, trends or opportunities for learning and improvement. There was no evidence that learning from incidents had been shared with staff to reduce the risk of recurrence. We found examples where care plans and risk assessments had not been reviewed or updated following incidents to ensure known risks were appropriately managed.

The provider's processes for identifying, recording, reporting and investigating incidents were not robust. This meant, opportunities to mitigate risks and improve people's safety were missed. This placed people at risk of avoidable harm from repeated incidents.

The provider did not always work well with people and partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The registered manager carried out pre-admission assessments prior to people moving into the service. The registered manager told us they took the lead on assessment to ensure that the home could meet the needs of people moving into the home.

On the first evening of our assessment, we reviewed the provider's personal emergency evacuation plans (PEEPs). While PEEPs were in place, summary documents did not always contain key information required to support a safe evacuation. For example, they did not consistently reference where door guards were in use.

We also found staff were not able to consistently confirm the number of people living at the home. This meant we could not be assured staff had immediate access to accurate information required to respond effectively in an emergency.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

There was evidence that the provider had submitted Deprivation of Liberty Safeguards (DoLS) applications. However, the provider's systems and processes for the oversight and monitoring of DoLS authorisations were ineffective. For example, it was not evident from the provider's tracking system whether approved DoLS authorisations contained conditions or how these were being monitored and met.

The provider had safeguarding policies. We were not assured these were up to date. For example, despite a policy having been reviewed in 2023, it referred to a local authority that had been abolished in 2021. The provider was unable to provide a more recent version of the policy before the conclusion of the assessment. This meant we could not be assured staff had access to accurate and current safeguarding guidance.

We found examples where safeguarding concerns had not been reported, had been reported late, or had not been adequately investigated. For example, incidents involving unexplained bruising had not been managed in a manner that demonstrated appropriate safeguarding oversight or professional curiosity to consider the potential causes of the bruising and mitigate the risks of further harm.

We were not assured that all safeguarding concerns had been notified to CQC as required. Where concerns had been reported, the information submitted by the registered manager did not always provide assurance that appropriate action had been taken to protect people.

The provider had not undertaken effective analysis of safeguarding concerns to identify themes, trends or opportunities for learning and improvement. This meant, the provider could not demonstrate that safeguarding risks were being effectively monitored or that appropriate action had been taken to reduce the risk of recurrence.

The provider's systems and processes for identifying, reporting, investigating and learning from safeguarding concerns were ineffective. The provider failed to ensure safeguarding concerns were consistently recognised, escalated and subject to appropriate oversight. This meant people were at risk of abuse, neglect and avoidable harm because concerns may not have been identified, reported or acted upon effectively to ensure their safety.

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.

People had risk assessments in place. However, these were not always personalised and often contained generic guidance rather than information tailored to the individual's specific needs.

Where risks had been identified, control measures were not always robust. For example, a person living with epilepsy did not have an agreed frequency for welfare checks when in their bedroom, and there was no evidence that assistive technology had been considered to support safe monitoring.

We found a significant number of people had door guards fitted to their bedroom doors. Although these were recorded in some care plans and risk assessments, the provider had not always demonstrated that all risks had been explored or that door guards were the least restrictive option available.

Staff told us that door guards had been implemented in response to the needs or behaviours of other people living in the home rather than the individual whose door was fitted with the device. This meant the impact on people's rights, choice and independence had not always been fully considered in a person-centred way.

The provider did not detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Although statutory compliance checks had been completed, we found environmental risks had not been adequately managed.

For example, risk assessments for people at risk of falls did not adequately consider the hazards posed by freestanding wardrobes. We also identified risks associated with radiators that had not been appropriately assessed or mitigated.

We found substances covered by the Control of Substances Hazardous to Health (COSHH) Regulations were not always stored securely. We also identified several environmental and maintenance issues that required attention. For example, a toilet door lock was in need of repair and window restrictors designed to protect vulnerable people from entrapment were not fully effective.

We found areas of the home required modernisation. For example, while adaptations had been made to the bath to support people who required moving and handling equipment on one unit, the environment lacked a homely feel and did not provide a comfortable or welcoming experience for people using the bathroom. We were not assured the use of the moving and handling equipment with the adaption made to the bath was safe.

We found some keys were attached to long chains in addition to coded door locks. We were concerned the length of these chains presented a potential ligature risk to people. The provider had not identified, assessed or mitigated this risk, which could place people at risk of harm.

We found the provider's arrangements for responding to emergency call bells were not effective. For example, two different call bell systems were in operation across the home, and staff were unable to hear the call bells sounding in all areas for which they were responsible.

Staff told us they relied on colleagues to alert them via radio when a call bell required answering. This placed people at risk of delays in receiving assistance, including during emergency situations.

We found that fire extinguishers were not being stored in their designated locations because people frequently moved them. The provider had not taken adequate action to consider alternative safe storage arrangements.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

We were not assured that robust safe recruitment processes were in place.

We found national guidance had not been followed in relation to Disclosure and Barring Service (DBS) checks undertaken through the DBS Update Service, and a reference had not been obtained from a staff member's most recent employer.

We identified inconsistencies in the provider's approach to pre-employment checks where staff transferred between roles and where individuals returned to work following a gap in employment.

The provider did not have an effective system for determining the number of staff and range of skills required to meet people's needs and keep them safe.

For example, we found the provider had not adequately considered the design and layout of the home when determining night-time staffing levels. We observed communal lounges left unsupervised despite some people being at risk of falls, which increased the risk that incidents may not be identified or responded to promptly.

The provider was unable to demonstrate that staff competency in enteral feeding and catheter care had been adequately assessed and maintained.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

While the overall cleanliness of the home was generally acceptable, the provider's systems and processes for infection prevention and control were ineffective.

Although there were not confirmed cases involving people living at the home at the time of the assessment, there had been reports of an on-going infection outbreak within the home for a significant period.

We were not assured by the provider's oversight and management of the outbreak. There was no effective system in place to monitor and track suspected or confirmed cases, which meant the provider could not demonstrate they had a clear understanding of the extent of the outbreak or the effectiveness of the control measures implemented.

We identified several infection prevention and control concerns during our assessment. For example, some clinical waste bins did not follow best practice guidance, as staff could not access the foot-operated pedal and were required to open the lids by hand. Given the outbreak within the home, we were concerned this practice increased the risk of cross-contamination.

Some carpets and flooring was damaged and required deep cleaning or replacement to ensure it could be effectively maintained to an appropriate hygiene standard. We noted unpleasant odours in two areas of the home, which indicated environmental standards were not consistently maintained. We also found unlabelled food items stored in satellite refrigerators and identified waste bins were not being used correctly.

Despite ongoing concerns raised by staff regarding infection prevention and control practices, the provider had not undertaken a structured debrief to identify lessons learned from the outbreak. Infection prevention and control audits completed by the provider had failed to identify a number of the concerns found during our assessment, demonstrating that audit processes were ineffective.

The provider's failure to effectively monitor, review and learn from infection prevention and control risks meant we could not be assured that appropriate measures were in place to protect people, staff and visitors from the risk of avoidable infection.

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

The provider had recently transitioned to a new electronic medication administration record (eMAR) system. We were told that the planning and implementation of the new system, and a change of pharmacy provider, had been rushed. Medicines management processes had become disorganised and lacked effective oversight.

The manager informed us on the first day of the assessment that the service was in the process of reverting to paper-based medicines records to improve oversight of medicines administration. However, we were not assured that this transition had been managed safely. Staff were unable to demonstrate that they had access to current protocols for the administration of 'as required' (PRN) medicines. This increased the risk of inconsistent and unsafe administration of medicines.

Medicines were not stored securely. We found oxygen cylinders had not been secured within the medicines room. The medicines room was found unlocked on several occasions during the assessment. We also found medicines fridges left unsecured and, on one occasion, a medicines trolley unlocked. Cabinets within the medicines room were unlocked, or keys had been left in locks, meaning medicines could be accessed by unauthorised individuals. These practices did not promote the safe management and storage of medicines.

The provider was unable to demonstrate that staff competency in the administration of rescue medicines had been assessed, monitored, and maintained. This meant we could not be assured that staff administering these medicines had the knowledge and skills required to do so safely.

Systems and processes for the recording, oversight, and administration of medicines were ineffective and did not provide assurance that people consistently received their medicines safely.

This meant, we were not assured that medicines management processes were safe and there was an increased risk of people experiencing harm.