CQC report explained · a residential care home
What the CQC found at Shannon Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2022
Shannon Court was rated Requires Improvement; inspectors found kind, generally safe care, but consent processes and management needed improvement.
Inspectors made an unannounced visit on 24 March 2022. They spoke with people, relatives and staff, reviewed care plans, medicines records, recruitment files and quality checks, and looked at infection control.
The home was rated Good for Safe, Caring and Responsive. People generally felt safe and were treated kindly. Staff supported people's independence, responded to health needs and provided activities. Improvements had been made to care plans, the environment and social activities.
The home was rated Requires Improvement for Effective and Well-led. Inspectors found that mental capacity checks and best-interest decisions were not always completed before restrictions were used. At least four people did not have the required assessments. The home was in breach of Regulation 11. It was also asked to improve some recruitment records, staffing arrangements and medicines guidance.
Managing risks
Inspectors found that risks such as falls and choking were identified and managed. Staff took extra steps to monitor a person at high risk of falls.
“One person in particularly was at high risk of falls and we observed staff constantly checking where the person was, walking with them when they mobilised and checking they used their mobility aid.” from the report
Kind and respectful staff
People and relatives gave positive feedback about staff. Inspectors saw staff offering reassurance, respecting choices and supporting people with dignity.
“The staff are kind and polite as far as I have experienced. They are doing a fine job. They're very patient.” from the report
Personalised care
Care plans included people's backgrounds, preferences and needs. End-of-life plans contained detailed information about what mattered to each person.
“Care plans held detailed information on people's backgrounds, which helped staff get to know people, their likes and dislikes.” from the report
Activities and social contact
Activities had improved since the previous inspection. People were offered group activities, sensory spaces and opportunities to spend time with others, without being forced to join in.
“There was good banter between people and staff and it was a very sociable occasion.” from the report
Staff training and support
Staff described their training as comprehensive. Records showed 96% compliance with training, and staff had regular opportunities to discuss their work and concerns.
“The training is very high standard. You have to keep up to date.” from the report
Mental capacity and consent
seriousAt least four people did not have capacity assessments in place, even though they lived in an environment with locked doors. The report says this did not always follow the Mental Capacity Act and led to a breach.
“We found a lack of capacity assessments for at least four people who lived at the service.” from the report
Staffing in some areas
needs fixingFeedback about staffing was mixed. Inspectors found that one living area needed more staff because one person required close monitoring, and an extra staff member was arranged during the day.
“However, some staff and relatives said in the living areas that had people with more advanced dementia, they felt they could do with an additional staff member.” from the report
PRN medicines guidance
needs fixingGuidance for some medicines taken when needed did not explain how people living with dementia might show that they needed them. The manager said the guidance would be reviewed.
“They did not include how the person may indicate they needed the PRN medicine.” from the report
Mixed views about food
minorPeople gave mixed feedback about meals. Alternatives were available, and a meeting with people and the chef had been arranged to discuss the food.
“The food is good in parts. If none of the menu items appeal to me, they will always do something else.” from the report
- 01Have capacity assessments and best-interest decisions now been completed for everyone affected by locked doors or other restrictions?
- 02How do you check that any sensor mats, locked doors or other restrictions are legally authorised and in each person's best interests?
- 03What staffing levels are now provided in the areas supporting people with more advanced dementia, and when is one-to-one support used?
- 04Have the PRN medicines protocols been updated to explain how each person may show they need a medicine?
- 05What was the outcome of the food forum, and what changes have been made to meals and activities since the inspection?
This was an unannounced inspection covering all five key questions and infection prevention and control; the provider was not asked to complete a Provider Information Return. This explanation was written from the published report of 14 May 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, June 2020
Rated Requires Improvement; inspectors found kind care and safe medicines, but risks, care plans and meaningful activities were not always managed well.
This was an unannounced inspection on 19 November 2019. Inspectors spoke with people, staff, a healthcare professional and relatives. They observed care and reviewed care, medicine, staff and management records.
The home was rated Requires Improvement overall. Safe, Effective, Responsive and Well-led were all rated Requires Improvement. Caring was rated Good. Inspectors found people were treated kindly and received their medicines as prescribed, but some risks were not properly assessed or recorded.
People living with dementia did not always receive enough meaningful activity or support suited to their needs. Care plans were sometimes inaccurate or out of date. The home had improved hydration support and acted on some issues, but its quality checks had not found important problems.
Kind and respectful staff
People generally described staff as kind and respectful. Inspectors saw staff protect privacy and offer choices about daily care.
“Some staff were seen to interact with people in a caring way.” from the report
Medicines managed safely
People received their medicines as prescribed. Staff had suitable training and competency checks, and medicine records included guidance for medicines given when needed.
“People received their medicines as prescribed and were supported by staff that had been appropriately trained and had their competency assessed.” from the report
Action to reduce falls
The home identified a pattern of falls and introduced extra support with hydration. Inspectors reported that the number of falls reduced after this change.
“The management team identified a trend in falls and this had resulted in a proactive approach to a new hydration initiative” from the report
People could raise concerns
The home had a complaints process, and people and relatives said they knew how to complain. Inspectors were told concerns were dealt with quickly.
“People and relatives told us they knew how to complain.” from the report
Risks were not always managed
seriousSome people did not have suitable risk assessments or clear guidance, including people with Parkinson's disease, seizures or difficulties chewing food. This created an increased risk of harm.
“Other risks to people were not always managed safely.” from the report
Care plans lacked detail
needs fixingSome assessments and care plans were generic, inaccurate or out of date. They did not always explain people's complex needs, choices or changes in circumstances.
“People's assessments in their care plans were not always accurate or up to date.” from the report
Limited meaningful activity
needs fixingPeople on the dementia wings sometimes had long periods without meaningful activities or positive interaction. Staff were often focused on tasks rather than conversation.
“Some people walked around the dementia units with nothing to occupy or stimulate them.” from the report
Training was not always effective
needs fixingA fire drill showed that some staff had limited knowledge of what to do in a fire. Induction and other training were not completed consistently or did not always prepare staff for their roles.
“Training had not always ensured staff had the skills and experience to support people effectively.” from the report
Checks did not find problems
needs fixingThe home's audits and provider checks had not identified the concerns found during the inspection. This limited management oversight of care quality and safety.
“There was a system of audits in place however they had not always been effective in identifying the issues found at the inspection.” from the report
- 01How do you now assess and review risks for people with dementia, Parkinson's disease, seizures or swallowing and chewing difficulties?
- 02How often are care plans reviewed, and how do you make sure they change promptly when a person's needs or circumstances change?
- 03What meaningful activities are available for people living with dementia, especially on the dementia wings?
- 04What extra communication support is available for people with advanced dementia or limited communication?
- 05What action has been completed since the inspection action plan, and how is the provider checking that it has worked?
This was an unannounced inspection covering all five CQC questions, including the premises and care provided; the previous overall rating was Good in 2017. This explanation was written from the published report of 2 June 2020 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
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- May 2022Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2016
Registered with the Care Quality Commission on 18 March 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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