CQC report explained · a nursing home
What the CQC found at Shaftesbury Horizons
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected by detailed risk assessments, safe medicines systems, safeguarding procedures and infection control arrangements. Recruitment checks were in place, but employment gaps had not always been explored as required.
- Effective?
- Good
- This question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Well-led?
- Good
- The home had positive leadership, staff felt supported, and people and relatives were invited to give feedback. However, quality assurance systems had not identified the recruitment shortfall.
What inspectors found, May 2023
Shaftesbury Horizons is rated Good; inspectors found safe care and kind staff, but recruitment checks and quality monitoring were not always reliable.
This was a focused inspection on 28 April 2023. Inspectors looked only at Safe and Well-led. They spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was found to be safe. People had detailed risk assessments, received medicines as prescribed, and staff knew how to report abuse. Infection prevention arrangements and equipment checks were also in place.
Inspectors found kind interactions and a positive culture. However, employment gaps had not always been checked as required, and the home's quality systems had not identified this. The manager acted during the inspection, and CQC recommended stronger governance checks.
The overall rating stayed Good because the ratings for the other three questions were carried forward from the previous inspection in 2018. They were not assessed during this visit.
Detailed risk planning
People had risk assessments covering their care and support needs. Staff understood these risks and knew how to respond, including in emergencies.
“Risk assessments were detailed; staff understood the risks and knew people well.” from the report
Safe medicines
Medicines were ordered, stored and given safely. Records were checked and guidance was available for medicines taken only occasionally.
“People received their medicines as prescribed. The service had arrangements for the ordering, storage, and disposal of medicines.” from the report
Kind staff interactions
Inspectors saw natural and encouraging interactions between staff and people. Feedback also described the home as safe and supportive.
“We observed many kind interactions between people and staff, they were both natural and encouraging.” from the report
Positive culture and feedback
Staff said they felt included and appreciated. People, relatives and staff were given opportunities to provide feedback, which was used to support improvements.
“The home actively sought feedback on the service it provided and used the information to drive improvement and learn lessons.” from the report
Recruitment checks
needs fixingThe recruitment process was not always followed. In particular, gaps in employment history had not always been explored in line with the provider's policy. The manager began putting this right during the inspection.
“employment gaps were not explored in line with the providers policy.” from the report
Quality monitoring
needs fixingThe home's governance systems had not identified the recruitment shortfall. CQC recommended stronger checks to make sure the systems consistently find problems.
“Quality assurance systems in place did not always operate effectively.” from the report
- 01What changes have been made to check employment gaps and follow the recruitment policy?
- 02How does the home now make sure its quality checks identify recruitment or other shortfalls?
- 03How are medicines that are taken only occasionally recorded and reviewed?
- 04How will my relative and our family be involved in care plan reviews and monthly meetings?
- 05What were the ratings for Effective, Caring and Responsive at the 2018 inspection, and when will these areas next be reviewed?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried forward from the 2018 inspection. This explanation was written from the published report of 17 May 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, June 2018
Shaftesbury Horizons was rated Good; inspectors found kind, personalised care, with a few minor safety and maintenance issues.
This was an unannounced comprehensive inspection on 2 and 3 May 2018. Inspectors spoke with people living at the home, relatives, staff and health professionals. They observed care and checked care records, medicines, staffing, recruitment, training, accidents, premises and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and were treated with kindness and respect. Staff knew people well and supported their choices, health needs, activities and independence.
Inspectors found enough trained staff, safe medicine systems, personalised care plans and good links with health professionals. They also found that some emergency fire plans had not been printed, some medicines lacked opening and expiry dates, and wet rooms needed refurbishment. These issues were discussed with the registered manager, and the fire plans were updated during the inspection.
Kind and respectful care
Staff were observed treating people warmly and with dignity. They asked permission before entering bedrooms and respected people's privacy and choices.
“Throughout the inspection we observed staff treating people with warmth, respect and dignity.” from the report
Personalised support
Care plans reflected people's likes, dislikes, routines, abilities and communication methods. Staff knew how each person preferred to receive care.
“People's care and support plans and records showed they received person centred care that was specific to their preferences, likes and dislikes.” from the report
Good health support
Staff referred people to suitable healthcare professionals and prepared hospital information packs. Specialist diets and complex healthcare needs were addressed.
“Some people lived with complex healthcare needs. Staff explained how they ensured people received best care suited to their needs by referring them to the appropriate healthcare professionals.” from the report
Activities and independence
People were supported to take part in college, volunteering, hobbies, community visits and other activities. The home aimed to maintain and improve people's independence.
“People were supported to live active lives and took part in a wide range of activities, hobbies and visits into the community.” from the report
Supportive management
People, relatives and staff described the home as open, friendly and well led. Regular audits, meetings and questionnaires were used to identify and act on improvements.
“There were quality assurance systems in place to ensure the quality and safety of the service for people and staff.” from the report
Fire evacuation paperwork
needs fixingThe latest personal emergency evacuation plans had not been printed for the fire grab pack. This could have made it harder to evacuate people safely, but the plans were updated before the inspection ended.
“This could mean in the event of a fire, evacuation staff may not know how to safely evacuate people.” from the report
Medicine dates
needs fixingSome medicines did not show when they had been opened or when they expired. The manager said a system would be put in place immediately.
“However, some medication did not have an 'opened by' and an expiry date noted on them.” from the report
Wet room condition
needs fixingWet rooms showed water damage and wear. Blackened grouting and cracked or peeling coverings could make cleaning more difficult and increase infection risk. The provider planned refurbishment.
“This meant there could be an increased risk of infection as cleaning these areas could be difficult.” from the report
Staff turnover and fire drills
minorA relative described staff turnover as high, and a staff member said sickness could sometimes make staffing difficult. Some staff also wanted more fire drill training.
“There is a good core of staff but staff turnover is high.” from the report
- 01Have all medicines been labelled with the date they were opened and their expiry dates?
- 02Have the wet rooms been refurbished, and how are they checked for water damage and infection risks?
- 03How often do staff practise fire evacuation, and are current personal emergency evacuation plans kept in the fire grab pack?
- 04What are the current staffing levels, staff turnover and arrangements for covering sickness?
- 05How would you support my relative's communication, healthcare needs, activities and preferred daily routine?
This was an unannounced comprehensive inspection covering the home, the care provided and all five key questions. This explanation was written from the published report of 15 June 2018 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 Shaftesbury Horizons
3 rated inspections over 7 years: the service has held its Good rating throughout.
- May 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- July 2012
Registered with the Care Quality Commission on 17 July 2012.
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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