CQC report explained · a residential care home
What the CQC found at Florence Shipley Residential and Community Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found safe recruitment, suitable staffing arrangements, regular risk reviews, safe medicines management and effective infection control measures.
- Effective?
- Good
- People had needs assessments and regularly updated care plans. Staff training was up to date, people were supported with food and drink, and the home worked with health professionals.
- Caring?
- Good
- People and relatives said staff were kind, respectful and helpful. Staff promoted dignity, privacy, independence and people's involvement in decisions.
- Responsive?
- Good
- Care plans included people's needs, choices, preferences and life histories. People could take part in activities, maintain relationships and raise complaints, which the home investigated.
- Well-led?
- Good
- The home had improved its quality checks and used audits and action plans to address issues. People, relatives and staff gave positive feedback about the management and person-centred approach.
What inspectors found, September 2022
Florence Shipley Residential and Community Care Centre was rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
This was an unannounced follow-up inspection on 16 August 2022. The inspector and an Expert by Experience spoke with people, relatives, staff and visiting professionals. They reviewed care records, medicines records, recruitment files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable training, detailed care planning and kind, respectful support.
The previous rating was Requires Improvement, published in November 2019. The home had been in breach of good governance, but inspectors found that improvements had been made and that it was no longer in breach of any regulations.
Safe care
People and relatives said they felt safe. Inspectors found that risks, accidents, medicines and infection control were managed appropriately.
“People and their relatives told us they felt the service was safe.” from the report
Personalised care
Care plans included people's histories, memories, work and family information. Staff used this knowledge to plan conversations and activities.
“Care plans contained detailed information on people's life history and included information on people's memories, employment and family.” from the report
Kind and respectful staff
Inspectors observed staff treating people with care and kindness. Staff respected privacy and dignity and encouraged independence.
“We observed staff responding to people with care and kindness throughout our inspection.” from the report
Improved management checks
The home had improved its quality assurance system since the previous inspection. Regular audits and action plans were used to identify and address problems.
“Since our previous inspection, improvements had been made to quality assurance systems which ensured all aspects of the service were regularly audited.” from the report
Activities and relationships
People could join group or one-to-one activities and were supported to keep in touch with relatives. Visitors were welcomed in line with people's choices.
“People were supported to take part in activities and hobbies both inside and outside of the service.” from the report
Staff deployment
minorSome staff were concerned about how staff were deployed across the different floors. Inspectors found that staffing levels were monitored and reflected people's needs, and relatives did not report concerns.
“Some staff told us they were concerned about how staff were deployed across the different floors in the service.” from the report
- 01How are staff deployed across the four floors, and how do you make sure each floor has enough staff at busy times?
- 02How often will my relative's care plan and risks be reviewed, and how will changes be shared with the family?
- 03How would you support my relative to take part in activities that match their interests, history and abilities?
- 04If my relative needs short-term reablement after hospital, how would the occupational therapist and physiotherapist be involved?
- 05What recent issues have been found through your audits, and what action was taken in response?
This was an unannounced follow-up inspection after the previous Requires Improvement rating; inspectors reviewed all five key questions and also checked infection prevention and control under Safe. This explanation was written from the published report of 22 September 2022 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 Requires Improvement; inspectors found safer, kinder care, but legal checks and management systems still needed improvement.
This was an unannounced inspection after the home had previously been rated Inadequate and placed in Special Measures. Inspectors spoke with people, relatives, staff and health professionals. They reviewed care records, medicines records and management audits.
The home had improved in all five areas. Staffing was safer, medicines were well managed, and people were protected from abuse and avoidable harm. People received kind and respectful care, personalised support and activities that matched their interests.
Some care and management systems were still inconsistent. Certain restrictions on people's liberty had not been properly checked for legal approval. There were also concerns about some referrals to health professionals, oral health assessments, staff competency checks and quality monitoring.
The overall rating changed from Inadequate to Requires Improvement. The home was no longer in Special Measures, but it remained in breach of Regulation 17 because its governance systems needed further development and embedding.
Safer staffing
Staffing levels had increased and inspectors found enough staff to respond promptly and safely. Staff were also recruited using appropriate checks.
“there were now enough staff to meet people's needs promptly and safely.” from the report
Kind and respectful care
People had warm relationships with staff. Inspectors saw staff protect privacy, offer reassurance and involve people in decisions.
“People had caring, kind supportive relationships with the staff who supported them.” from the report
Personalised support
Care plans gave staff detailed information about people's needs and preferences. Staff discussed people's changing needs at daily handovers.
“People had care plans which were personalised and detailed.” from the report
Improved safety systems
Risks were assessed and reviewed, and lessons were taken from accidents and safeguarding concerns. Medicines were managed safely.
“At this inspection this had improved, and risks were assessed, mitigated and reviewed.” from the report
Liberty restrictions
seriousSome restrictions on people's liberty had been used without first checking whether the person had capacity to agree to them. This raised a legal safeguard concern.
“some people had a restriction of their liberty in place without considering whether they had capacity to consent to this.” from the report
Governance breach
seriousThe provider's quality systems did not yet give reliable oversight. Some audits were too infrequent, falls information was not fully analysed and errors were not always followed up.
“The systems to assure good governance required improvement and further embedding.” from the report
Health professional referrals
needs fixingHealth professionals continued to have concerns about how often and how appropriately some referrals were made. The home had not yet met with them to address this.
“there continued to be concerns about the frequency and appropriateness of the referrals being raised.” from the report
Staff competency checks
needs fixingOne staff member made three medicines recording errors, but their competency had not been reviewed afterwards.
“we found one member of staff had made three errors in recording medicines administration and no action had been taken to review their competency.” from the report
Oral health information
needs fixingSome oral health assessments did not give staff enough guidance about how to support people's mouth care.
“Some oral health assessments did not have enough information” from the report
- 01How do you now check that any restriction on a person's liberty has the correct capacity assessment and legal authorisation?
- 02How are medicines recording errors followed up, and how do you check staff competency afterwards?
- 03How often do you review medicines audits for each unit, and who checks that identified errors are resolved?
- 04How do you analyse falls and other incidents over time to identify patterns and prevent recurrence?
- 05What has changed in the way you make referrals to health professionals and work with them?
This was a planned, unannounced inspection covering the overall service and all five key questions, following the previous Inadequate rating. This explanation was written from the published report of 8 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 Florence Shipley Residential and Community Care Centre
4 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- September 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Florence Shipley Residential and Community Care Centre →
- November 2019Requires improvementup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Florence Shipley Residential and Community Care Centre →
- March 2019Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2018Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2016
Registered with the Care Quality Commission on 24 February 2016.
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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