CQC report explained · a residential care home
What the CQC found at Shangri-La Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, December 2017
Shangri-La Residential Home was rated Good; inspectors found safe, kind and personalised care, with a medicines labelling issue to fix.
The inspection was unannounced and took place on 10 October 2017. Two inspectors and an expert by experience visited after concerns had been raised about safety and quality. They spoke with people living at the home, relatives, staff and health professionals. They also checked care records, staff files, complaints, accidents and quality checks.
The inspectors rated the home Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. They found enough staff, detailed risk assessments, trained staff, good support with food and health care, respectful relationships and personalised care plans. People were offered activities and families were involved in care reviews.
The home had been rated Requires Improvement in December 2016, with four legal breaches. This inspection found that the provider had put things right and was meeting those requirements. Inspectors did find that some topical creams did not have an opened-on date, so the manager said this would be corrected immediately.
Enough staff
Inspectors found staffing levels gave staff time to respond promptly and spend time with people without rushing.
“There was enough staff to meet people's needs and staff had the time to engage with people in a relaxed and unhurried manner.” from the report
Respectful care
Staff treated people with dignity, listened to them and supported their choices and independence.
“Staff developed caring and positive relationships with people and treated them with dignity and respect.” from the report
Improved management
The provider had acted on the problems found at the previous inspection. Quality checks were being used to monitor care, medicines and the environment.
“At this inspection we found the provider had rectified the breaches found at the last inspection; the home is now rated 'Good'.” from the report
Topical cream labelling
needs fixingSome topical creams did not show when they had been opened. Inspectors said the system was not robust, and the manager agreed to take immediate action.
“However, not all topical creams had an 'opened on' date.” from the report
- 01How did you correct the problem with recording when topical creams were opened?
- 02How do you now check that topical creams are used before their safe-use date?
- 03How are staffing levels reviewed when a person's needs or routines change?
- 04How will my relative and our family be involved in care plan reviews?
- 05What activities are available for people who prefer individual support rather than group activities?
This was an unannounced inspection of the overall service, covering all five CQC questions, with interviews, observations and checks of care and management records. This explanation was written from the published report of 1 December 2017 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 2017
Rated Requires Improvement; inspectors found kind care, but concerns about risk assessments, consent, care records and oversight.
This was an unannounced comprehensive inspection on 5 and 6 December 2016. Inspectors spoke with people living at the home, visitors and staff. They reviewed care and staff records, medicines information, complaints, policies, rotas and training records. They also observed care and received feedback from health and social care professionals.
People generally felt safe and said staff were caring, kind and respectful. Staffing levels, recruitment checks, training, medicine storage and medicine administration were satisfactory. People were supported with meals and healthcare, and complaints were investigated.
However, some risk assessments were generic or out of date. Care plans did not always give personalised information. Records about nutrition, fluids, medicines and people's ability to make decisions were not always complete or accurate. The systems used to check quality had not found or fixed all these problems.
The overall rating was Requires Improvement. Caring was rated Good. Safe, Effective, Responsive and Well-led were all rated Requires Improvement. The home had four breaches of regulations, and the provider was asked to send an action plan.
Kind and respectful staff
People described staff as caring and compassionate. Staff respected privacy, dignity and people's choices.
“People were supported by caring staff who respected people's privacy and dignity.” from the report
Staffing and recruitment
Inspectors found staffing levels were enough to meet people's needs. Recruitment checks were completed before staff started work.
“Staffing levels were planned and sufficient to meet the needs of people.” from the report
Training and support
Most staff training was in date. Staff said the training was useful and that managers supported them.
“Staff told us they found the training to be enjoyable and equipped them to do their job safely and effectively.” from the report
Complaints process
People knew how to raise concerns and felt they would be listened to. Inspectors found complaints had been handled in line with the provider's procedure.
“The Home's complaint procedure was displayed in the reception area.” from the report
Risk information was not personal or current
seriousSome risk assessments used generic information rather than describing the individual person's risks. Important advice about eating and nutrition was not always recorded or passed to the cook.
“Risk assessments had been completed in people's records, but in some cases these were generic risk assessments.” from the report
Missing capacity and consent checks
seriousThe home had not completed mental capacity assessments for some people. Pressure mats and bed rails were used without evidence that consent or best-interests decisions had been properly considered.
“There was no evidence people had been asked for their consent to use bed rails and no mental capacity assessments had taken place with people.” from the report
Care plans were not personalised
seriousCare plans were often basic and did not clearly record changing needs, such as weight loss or information from health professionals. Staff knew people well, but could not safely rely on this instead of accurate care plans.
“The care and treatment of people was not always person centred.” from the report
Records and checks were unreliable
seriousNutrition and fluid records were incomplete or inaccurate, and some medicine records had gaps. Quality checks had not picked up these issues.
“Accurate records were not maintained and there was not an effective system to monitor the service and to drive improvement.” from the report
- 01How will you make sure each person's risk assessments describe their own risks and are updated when their needs change?
- 02How do you assess capacity and record consent or best-interests decisions for bed rails, pressure mats and any other restrictions?
- 03How will you make sure care plans include current information about nutrition, weight loss, fluids and advice from health professionals?
- 04What checks now ensure medicine records, fluid charts and other care records are complete and accurate?
- 05What action was taken in response to the four breaches, and how do managers check that improvements have lasted?
This was an unannounced comprehensive inspection covering all five questions and the overall rating, following a previous inspection in November 2015. This explanation was written from the published report of 1 March 2017 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 Shangri-La Residential Home
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- December 2017Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 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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Most charge £1,020 to £1,260 a week. 23 can care for a couple. 14 years' experience on average.
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