CQC report explained · a residential care home
What the CQC found at Shrewsbury
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found environmental hazards, medicines that were not always stored safely, incomplete incident records and risk assessments that were not always reviewed on time.
- Effective?
- Good
- The report does not give a rating for Effective. It says staff had relevant training, but some additional training was needed and some capacity assessments used wording that suggested the outcome was already decided.
- Caring?
- Good
- The report does not give a rating for Caring. Inspectors found staff were dedicated to people's needs and observed people being involved in day-to-day decisions.
- Responsive?
- Good
- The report does not give a rating for Responsive. Inspectors found people had activities, but relatives said there were not enough opportunities in the home or community and communication support was not always available.
- Well-led?
- Requires improvement
- Governance systems and audits did not always identify problems. Staff reported inconsistent leadership and several management changes, while records were not always complete or person-centred.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found risks with the environment, medicines and management systems.
This was an unannounced inspection on 26 and 27 April and 15 May 2023. Inspectors reviewed four care plans, three people's medicine records and three staff files. They spoke with people, relatives, staff and professionals.
The home was not always safe. Inspectors found hazards such as a split fire door, a broken radiator cover, unsafe storage of cleaning products and areas that were not secure. Medicines were not always stored correctly, some creams were out of date and medicine records did not always match.
The home was also not always well-led. Checks and audits did not always find problems, records were incomplete and there was no registered manager at the time. Staff described several management changes and said stronger leadership was needed.
The overall rating changed from Good at the previous inspection to Requires Improvement. The home must improve, and the CQC will ask for an action plan and monitor progress.
Safer recruitment
Staff were recruited using checks of qualifications, character, background and criminal records.
“People were supported by staff who were safely recruited and had received training relevant to their role.” from the report
Protection from abuse
Relatives said they felt their family members were safe. Staff had training in recognising and reporting abuse and said they would speak up.
“People were protected from the risk of abuse. People's relatives all told us they felt their relative was safe.” from the report
Support during a crisis
During a crisis situation, staff showed dedication to keeping everyone safe. A detailed assessment and strategies were in place.
“At the time of our initial visit the home was supporting someone through a crisis situation and all staff showed a dedication to keeping everyone safe.” from the report
Involvement in decisions
Inspectors saw people being involved in everyday choices about what they wanted to do.
“Staff had received training in MCA, and we observed people being involved in day to day decisions about what they wanted to do.” from the report
Environmental hazards
seriousInspectors found several risks that could cause harm, including a damaged fire door, unsafe storage and unsecured areas.
“We found a number of issues within the environment which had the potential to cause harm.” from the report
Medicines not always managed safely
seriousOne medicine was not kept in a lockable fridge, some creams were out of date and thickener was not secure. Medicine counts did not always match.
“People's medicines were not always managed in line with requirements.” from the report
Weak checks and records
seriousAudits did not always identify problems, and records were incomplete or stored in the wrong place. This led to a breach of the governance regulation.
“The governance processes in place were not adequately identifying risk or concern within the service.” from the report
Limited activities
needs fixingRelatives said there were not enough activities in the home or community. Inspectors found limited evidence of meaningful activity in daily records.
“People did not always have the opportunity to achieve their desired outcomes.” from the report
Inconsistent leadership
needs fixingThere was no registered manager at the inspection. Staff described several management changes and said stronger leadership was needed.
“The leadership in the service had been inconsistent and we were advised this had, had an impact on the overall progress of the service.” from the report
- 01What has been done to fix the fire door, radiator cover, cleaning product storage and other environmental hazards?
- 02How are medicines now stored, including refrigerated medicines, creams and thickener, and how are medicine counts checked?
- 03Who is currently responsible for the home, and when will a registered manager be in post?
- 04What changes have been made to provide more activities in the home and community?
- 05How are communication needs recorded and supported, including sign language or picture references?
The inspection covered the premises and care provided, but the report gives ratings only for Safe and Well-led; ratings for Effective, Caring and Responsive are not given. This explanation was written from the published report of 4 July 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2019
Rated Good overall; inspectors found safe, kind and personalised care, but the home’s leadership and quality checks Requires Improvement.
Inspectors made an unannounced visit on 30 September and 1 October 2019. They spoke with five people living at the home and ten staff. They also reviewed care records, staff files and management records.
People were described as safe, well cared for and supported to make choices. Staff knew people well, promoted independence and helped with health appointments, activities and relationships. Medicines, risks and safeguarding arrangements were found to be managed safely.
The main weakness was management oversight. Required checks were not always recorded, audit information was spread across different folders, and some incident records were not processed promptly. The home was rated Good in four areas, but Requires Improvement for being well-led.
The overall rating stayed Good, the same as at the previous inspection in 2016. However, the well-led rating fell from Good to Requires Improvement. The manager had identified some of the problems and new systems were introduced, but inspectors said they would check progress at the next inspection.
People felt safe
People said they felt safe, and staff understood how to recognise and report abuse. Risks linked to care, activities and the environment were assessed.
“People continued to be kept safe from harm.” from the report
Personalised support
Staff knew people's needs, communication methods and interests. Support plans reflected personal goals and were reviewed with people, families and professionals.
“People continued to receive personalised care. Staff knew people well and understood their needs and personalities.” from the report
Choice and independence
People were involved in decisions about their care and home. Staff supported independent living skills and used communication methods such as sign language.
“People's independence was promoted and staff encouraged independent living skills.” from the report
Kind and respectful care
Inspectors found relaxed interactions and said people's privacy and dignity were respected. People reported feeling well cared for.
“People were treated with kindness and care and interactions between people and staff were relaxed.” from the report
Safe medicines support
People received medicines when needed. Care plans and guidance covered medicines given when required, and the provider followed recognised guidance on reducing unnecessary medicines.
“People's medicines were managed safely and they received their medicine when they needed them.” from the report
Incomplete quality checks
needs fixingRequired kitchen checks were not consistently recorded. Staff said checks were sometimes completed but not recorded because nobody checked the records.
“We found records were not consistently completed to show these checks had been completed.” from the report
Poorly organised audits
needs fixingHealth and safety and medicines audits were spread across folders or had not been completed. This made information harder to find and weakened management oversight.
“The provider had not ensured information relating to quality audits were consistently organised and easily accessible.” from the report
Leadership change
needs fixingThere was no registered manager at the inspection. A new manager had been in post for about a month and was applying to become registered.
“The service did not have a manager registered with the Care Quality Commission.” from the report
Some support gaps
needs fixingSome staff had not received autism training. People's end of life wishes had not been fully discussed or recorded, and one person found activities a bit boring.
“Some staff told us they had not received training in supporting people with autism.” from the report
- 01What checks are now completed for food temperatures, fridge and freezer temperatures, and cleaning, and how do managers make sure they are recorded?
- 02How are health and safety, medicines and fire safety audits stored so they can be found and checked easily?
- 03Have all staff now received training in supporting people with autism and dementia awareness?
- 04How will you discuss and record each person's end of life wishes with them and their family?
- 05What activities are available for someone with particular hobbies and interests, and how can they help plan them?
This was an unannounced inspection covering all five CQC questions; the report says the service was a care home and that premises and care were both looked at. This explanation was written from the published report of 16 November 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Shrewsbury
4 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019Goodstayed GoodSafe: GoodWell-led: Requires improvement
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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