CQC report explained · a residential care home
What the CQC found at Shaftesbury House Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found systems to assess and reduce risks, safe recruitment and medicines arrangements, suitable infection control, and learning from incidents. Staff were available when needed and people received medicines as prescribed.
- Effective?
- Good
- This key question was not inspected during this focused visit. The earlier rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. The earlier rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- Care records described people's needs and preferences. People were supported with communication, activities, relationships, complaints and end of life choices.
- Well-led?
- Good
- The registered manager understood their responsibilities. Audits, surveys, an action plan and staff training were used to monitor the service and make improvements.
What inspectors found, August 2022
Shaftesbury House Residential Care Home was rated Good; inspectors found improvements in safe, responsive and well-led care, but some systems were still being strengthened.
This was an unannounced focused inspection on 29 July 2022. One inspector spoke with five residents, relatives and five staff, observed care and activities, and checked care records, risk assessments, recruitment, training and management records.
The home was rated Good for Safe, Responsive and Well-led. Inspectors found better care records, safe medicines systems, suitable infection control, timely staff support, activities, complaint handling and management checks. People were supported to receive visitors and take part in activities.
The previous overall rating was Requires Improvement, published in March 2019. The report says improvements had been made. Effective and Caring were not inspected during this visit, so their earlier ratings were used when calculating the overall Good rating.
Risk management
Care records included guidance about risks such as falls, pressure ulcers, mobility and health conditions. Equipment and environmental safety checks were also completed.
“Records showed that risks in people's daily living were assessed and staff were provided with guidance in how to reduce them.” from the report
Medicines and infection control
Inspectors found medicines were stored, ordered and recorded safely. They were also assured about infection prevention, protective equipment, testing and outbreak arrangements.
“There were systems in place for the safe storage, ordering and returning medicines and people received their medicines as prescribed.” from the report
Personalised care
Care records had improved and described people's needs, preferences, communication and end of life choices. Staff discussed people's wellbeing at handovers.
“The records documented people's specific needs and how they were to be met.” from the report
Activities and family contact
People had access to group and one-to-one activities, outings and community trips. The home supported visits from relatives and friends.
“People confirmed they were supported to have visits from their relatives and friends.” from the report
Management oversight
Audits and an action plan helped identify shortfalls and track improvements. Staff training was reviewed and people, relatives and staff were asked for their views.
“A programme of audits were in place, which assisted the provider to monitor the service provided and identify any shortfalls and address them.” from the report
Staffing calculations still being strengthened
minorThe manager used a dependency tool to help calculate staffing levels, but the provider was still reviewing it to make it more robust.
“This was being reviewed by the provider to make it more robust.” from the report
Manager recruitment
minorThe existing registered manager had secured another role with the provider. The provider was recruiting for the manager position, although the current manager remained in post at the inspection.
“The provider was actively recruiting to fill the manager role; however, the current registered manager was continuing as registered manager for this service until a new manager was in post.” from the report
Some activities did not suit everyone
minorOne person said they had been bored and did not enjoy the group activities. They instead helped maintenance staff with tasks such as testing fire safety equipment.
“One person told us how they had been bored and not interested in the group activities provided” from the report
- 01How are you using the staffing dependency tool, and what changes are being made to make it more robust?
- 02Who is now managing the home, and how will leadership be maintained while a new manager is recruited?
- 03How do you find activities that suit residents who do not enjoy group activities?
- 04How are care plans and risk assessments reviewed when a resident's needs or preferences change?
- 05What improvements have been made since the last inspection, and how do you check that they are continuing?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their earlier ratings were used to calculate the overall rating. This explanation was written from the published report of 23 August 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, March 2019
Rated Requires Improvement; inspectors found kind and effective care, but risks, care records and management still needed attention.
This was an unannounced comprehensive inspection on 30 January 2019. Inspectors spoke with people living in the home, relatives and staff. They observed care and checked care records, medicines, recruitment and management systems.
The home was rated Good for Effective and Caring. People generally received the support they needed, had access to health professionals, and were treated with kindness, dignity and respect.
The home was rated Requires Improvement for Safe, Responsive and Well-led. Choking risks were not clearly recorded, care plans were not sufficiently person-centred, and end of life wishes were not always documented. Inspectors also found that some concerns had not been followed up promptly.
There had been improvements since the previous inspection. The home was no longer in breach of Regulation 12, and Effective had improved from Requires Improvement to Good. However, the overall rating remained Requires Improvement because further improvements were still needed.
Kind relationships
People and staff had positive relationships. Inspectors saw staff communicating respectfully and responding reassuringly when someone became distressed.
“There was a relaxed and friendly atmosphere in the service and people and staff clearly shared positive relationships.” from the report
Health and nutrition support
People could access health professionals when needed. Systems for monitoring food and drink had improved, including support for people with special dietary needs.
“Improvements had been made in how the service assessed how much people had to eat and drink.” from the report
Staff training
Staff had training relevant to people's needs, and regular one-to-one supervision meetings had improved since the previous inspection.
“Since our last inspection improvements had been made and staff were now receiving regular one to one supervision meetings.” from the report
Clean and suitable environment
The home was visibly clean and had systems to reduce infection risks. The environment had been refurbished and adapted for people with limited mobility.
“The service was visibly clean.” from the report
Choking risks
seriousRecords did not consistently explain how choking risks should be reduced or incorporate professional guidance. Inspectors said this could lead to unsafe care.
“Information about how to reduce the risks and guidance from other professionals was inconsistently recorded and not always incorporated into the care plans.” from the report
Care plans
needs fixingThe four care plans reviewed were not written in a person-centred way and did not explain clearly how care tasks would benefit each person.
“We reviewed the care plans of four people who used the service, none were written in a person centred way and none detailed how the tasks identified to support the person would have positive outcomes for people using the service.” from the report
End of life wishes
needs fixingEnd of life decisions were recorded inconsistently. One person receiving end of life care did not have a plan describing their wishes and palliative care needs.
“One person's records who was identified as receiving end of life care did not have an end of life care plan in place which identified the person's wishes, and the specific support required for palliative care.” from the report
Delayed safeguarding response
seriousA concern about missing personal items had not initially been followed up or referred to safeguarding. The registered manager acted after inspectors raised it.
“The allegation was made in December 2018, which had not been followed up and no safeguarding referral had been made.” from the report
Limited records of one-to-one time
needs fixingStaff spent time with people in their bedrooms, but this was not consistently recorded. The records did not show the effect of this interaction on people's wellbeing.
“There was limited information to show how people had received meaningful interaction on a one to one basis and when they chose to spend their time in their bedrooms.” from the report
- 01How are choking risks assessed now, and where can we see the clear instructions staff follow for each person?
- 02Have all care plans been rewritten in a person-centred way, and how are they checked for accuracy?
- 03How do you record and review each person's end of life wishes and palliative care needs?
- 04How do you record meaningful one-to-one time for people who choose to stay in their bedrooms?
- 05What changes were made after the management restructure and the planned electronic care records?
This was an unannounced comprehensive inspection covering all five key questions, with the previous overall and key question ratings reviewed against the findings. This explanation was written from the published report of 14 March 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 Shaftesbury House Residential Care Home
4 rated inspections over 7 years: the service has held its Good rating throughout.
- August 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Shaftesbury House Residential Care Home →
- March 2019Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Shaftesbury House Residential Care Home →
- January 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 December 2010.
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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