CQC report explained · a nursing home
What the CQC found at Shannon Court Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm, with suitable risk assessments, enough staff, safe recruitment and effective infection control. They identified some medicines recording and timing issues.
- Effective?
- Good
- This question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Well-led?
- Good
- Inspectors found clear management arrangements, good quality checks and an open culture. The home had acted on the previous inspection findings and was no longer in breach of Regulation 17.
What inspectors found, March 2023
Rated Good; inspectors found safer systems and stronger management, with some medicines records still needing attention.
This was an unannounced focused inspection. Inspectors visited on 22 February 2023 and reviewed information, care records, medicines records, recruitment files and quality checks. They also spoke with people, relatives and staff.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, suitable risk assessments, safe infection control and generally safe medicines management. People and relatives spoke positively about the care, staff and management.
There were two medicines issues to address. One person's when-required medicine was given too close together on several occasions, and some medicine charts did not explain clearly how medicines should be given. The manager identified the first issue and took action.
The previous overall rating was Requires Improvement, published on 5 October 2021. The provider had been in breach of Regulation 17 about accurate medicine records, but inspectors found enough improvement and said the home was no longer in breach.
Enough staff
Inspectors found staffing levels were sufficient for people's assessed needs. People and relatives also said there were enough staff available.
“There were enough staff on duty to meet people's assessed needs.” from the report
Safe recruitment
The provider completed identity, employment, reference, right-to-work and criminal record checks before staff started work.
“The provider carried out robust pre-employment checks prior to staff working at the home.” from the report
Good management oversight
The management team used quality checks to identify actions, owners and completion dates. Inspectors found the home had addressed the previous governance problem.
“There were quality assurance processes in place which ensured the quality of service was maintained and any shortfalls identified and acted upon.” from the report
Positive relationships
People and relatives described staff as kind, approachable and respectful. Inspectors found people's privacy, dignity, equality and communication needs were considered.
“People told us they were well treated, and their equality and diversity were respected.” from the report
Medicine given too close together
needs fixingOne person's when-required medicine was given too close together several times. The manager found this during the inspection and took appropriate action.
“One person receiving PRN (when required) medicine had it given too close together on several occasions.” from the report
Some medicine directions incomplete
needs fixingSome medicine administration charts did not say clearly how certain medicines should be given, such as whether they should be crushed and dissolved.
“some medication administration charts needed to be updated with directions on how to administer the medicines, for example, crushed and dissolved in juice.” from the report
- 01What action was taken after the person's when-required medicine was given too close together?
- 02Have all medicine administration charts been updated with clear instructions, including how medicines should be prepared?
- 03How do you check that medicine doses are given at the correct time?
- 04Which ratings for Effective, Caring and Responsive were carried over from the previous inspection?
- 05How will the quality checks make sure the improvements from the previous inspection continue?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 8 March 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, October 2021
Shannon Court Care Centre is rated Requires Improvement; medicine errors and weak checks created risks, although care was kind and staffing was sufficient.
This was an unannounced focused inspection on 5 August 2021. Inspectors checked whether the home had acted on problems found at the previous inspection, focusing only on Safe and Well-led.
The home had improved some medicine arrangements, but inspectors found two medicine-related recording and management errors. One stopped medicine continued for four days, and there was not always enough time between doses of paracetamol. Staff medicine competence had not yet been checked, and incident records were incomplete or missing.
Inspectors found suitable safeguarding systems, enough staff on the day, safe recruitment, individual risk assessments and effective infection control. People received kind and patient support, and relatives were kept informed.
The overall rating remains Requires Improvement. The home has had this rating for four consecutive inspections. The provider must produce an action plan, and the CQC issued a warning notice for poor governance.
Staffing
Inspectors found enough staff to meet people's needs on the day of the visit. Staff recruitment checks were also in place.
“There were sufficient staff to meet the needs of the people using the service on the day of the inspection.” from the report
Kind support
People said they were happy with their care. Inspectors saw staff offering support in a kind and patient way.
“People we spoke with were happy with their care and support and we observed staff offering support in a kind and patient manner.” from the report
Safeguarding
Staff had safeguarding training and understood how to report concerns. Safeguarding records and actions were in place.
“All staff had completed safeguarding training. Those we spoke with demonstrated a good understanding of the issues and were confident to report any concerns.” from the report
Infection control
Inspectors were assured that the home was using protective equipment safely and had arrangements to prevent and manage infection outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicine errors
seriousInspectors found that stopped medicines continued to be given, and one record showed that doses of paracetamol were given too close together. These errors had the potential to cause harm.
“Records showed that 'stopped' medicines continued to be given, in one case for four days.” from the report
Weak medicine oversight
seriousThe new electronic medicine system was not being checked sufficiently. Staff training had taken place, but their practical competence had not yet been assessed.
“System reports were not routinely used to audit the safe handling of medicines.” from the report
Incomplete incident records
needs fixingMedicine errors were not consistently reported, so the home could not reliably show what had happened or learn from it.
“Incident reports had not been made when errors occurred.” from the report
- 01What changes have you made to prevent stopped medicines being given after this inspection?
- 02How do you now check that there is enough time between repeated doses of medicines such as paracetamol?
- 03Have all staff who give medicines had their competence assessed, and how often is this repeated?
- 04How are medicine errors recorded, investigated and used to prevent the same problem happening again?
- 05What progress has been made on the action plan following the Warning Notice?
This was an unannounced focused inspection of Safe and Well-led only; ratings for Effective, Caring and Responsive were carried over from the previous comprehensive inspection. This explanation was written from the published report of 5 October 2021 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 Shannon Court Care Centre
5 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- November 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2018
Registered with the Care Quality Commission on 10 April 2018.
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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