CQC report explained · a nursing home
What the CQC found at Shelburne Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Medicines, staffing, recruitment, fire safety and safeguarding arrangements were satisfactory. However, some risk assessments were not robustly reviewed, which caused inconsistency in practice and outcomes.
- Effective?
- Good
- Staff had relevant training, regular supervision and support. People received help from health professionals, and their food and specialist diets were managed appropriately.
- Caring?
- Good
- Inspectors observed kind, respectful care and said people's dignity was protected. People and families were involved in care decisions.
- Responsive?
- Good
- People had personalised care plans, activities and support at the end of life. There was a complaints process and one complaint had been dealt with appropriately.
- Well-led?
- Good
- Staff felt supported by the management team. Audits, meetings, handovers and daily checks were used to monitor the service and follow up actions.
What inspectors found, August 2018
Rated Good overall, but inspectors found risk assessments and some resuscitation records were not always reliable, so safety Requires Improvement.
Inspectors visited on 16 and 18 May 2018. The first day was unannounced. They spoke with people living in the home, relatives, staff and health professionals. They also reviewed care records, medicines records and quality checks.
The home had improved since the March 2017 inspection. Staffing levels and medicines management had improved, and the provider was now meeting the regulations that had previously been breached.
Inspectors rated the home Good overall. Effective, Caring, Responsive and Well-led were rated Good. Safe was rated Requires Improvement because some risk assessments and records were not reviewed consistently, including mattress settings, weights and resuscitation decisions.
Improved medicines management
Inspectors found that medicines were being given as prescribed. Records and stock checks, including checks of controlled medicines, were correct during the visit.
“We found records in order and stock checks were correct at the time of our visit.” from the report
Kind and respectful care
People and relatives gave positive feedback about staff. Inspectors saw kind interactions and care that respected people's dignity and privacy.
“We saw many positive social interactions and actions of kindness from all staff.” from the report
Staff training and support
Staff had a structured induction, training for their roles and regular supervision. Staff caring for people with complex nursing needs had specific training.
“People received care and support from staff that were provided with training to support people effectively.” from the report
Activities and personal choices
People could join activities, personalise their rooms and take part in events. The home also supported an individual to continue gardening.
“The service offered a range of activities for people to take part in.” from the report
Improved management systems
The home had improved its monitoring since the previous inspection. Managers held regular meetings, carried out audits and followed up actions.
“The service carried out audits monthly. We saw where actions were required, these were completed.” from the report
Conflicting resuscitation records
seriousOne person's resuscitation decision had been recorded without the person's or family's understanding or consent. Different records gave conflicting instructions, creating a safety risk.
“Further inconsistency arose because the records folder showed that the DNAR form was in place, but the daily handover sheet noted that the person was "for resuscitation".” from the report
Call bell response was not always quick
needs fixingOne person said staff did not always respond quickly when they used the buzzer. This was different from inspectors' observation that call bells were answered promptly during the visit.
“I use my buzzer, they don't always come quickly” from the report
- 01How are you now checking mattress settings, weights and other risk assessments so they are reviewed and acted on consistently?
- 02How do you make sure resuscitation decisions are agreed with the person or their family when appropriate, and recorded consistently in every document?
- 03What is the usual response time to call bells, including at weekends and at night?
- 04How will you make sure people who want to use the home's van or join activities are supported to do so?
- 05What changes were made after the March 2017 inspection, and how are you checking that the improvements remain in place?
This was an inspection of the overall service covering all five key questions; the previous March 2017 inspection had found breaches involving medicines, records and staffing, and this inspection checked the improvements. This explanation was written from the published report of 1 August 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.
What inspectors found, June 2017
Rated Requires Improvement; inspectors found caring and effective support, but staffing, medicines and record-keeping were not consistently safe.
This was an unannounced comprehensive inspection on 8 and 9 March 2017. Inspectors spoke with people living at the home, relatives, staff and managers. They reviewed care records, medicine records, staff files and management records, and toured the building.
The home was rated Good for effective care and for caring. People were supported by trained staff, had enough to eat and drink, could access healthcare, and were generally treated with kindness, dignity and respect. People were involved in choices about their care and daily lives.
The home was rated Requires Improvement for safe care, responsiveness and leadership. There were not always enough staff, and inspectors found several problems with medicine records and medicines management. Some care plans lacked clear, personalised guidance, while quality checks had not identified or corrected repeated problems.
The report found three breaches of regulations covering safe care and treatment, good governance, and staffing. The provider was asked to say what action it would take, and CQC said it would check whether that action had been completed.
Kind and respectful care
Inspectors saw staff treating people with dignity and respect. People were given time to express their wishes and their choices were respected.
“Staff were kind, compassionate and respectful and treated people with dignity and respect which promoted their wellbeing.” from the report
Staff training
Staff had training in areas including safeguarding, moving and handling, food safety and infection control. They also received supervision and appraisals.
“People were supported by staff who had the training and knowledge to support them effectively.” from the report
Food and healthcare
People had a choice of meals and staff knew about individual dietary needs. People could see health professionals when needed, with visits recorded in care plans.
“People had access to healthcare services and people's nutrition was well maintained.” from the report
Activities and personal interests
People were supported to choose how to spend their day. The home offered group activities and one-to-one sessions linked to people's interests and past lives.
“People were supported to spend their day as they chose.” from the report
Recruitment checks
The home completed relevant checks before staff worked unsupervised, including references, right-to-work checks and criminal record checks.
“Records relating to recruitment of staff contained relevant checks that had been completed before staff worked unsupervised in the home to ensure they were of good character.” from the report
Staffing levels
seriousThe planned staffing level was not maintained, especially on the first floor. People and staff described waiting for help, and breaks sometimes left too few staff available.
“There were not sufficient staff to meet people's needs.” from the report
Medicines management
seriousMedicine stocks did not always match records. Instructions were sometimes kept on loose notes, allergy information was missing from some medicine records, and some required guidance was absent or unclear.
“The management of people's medicine was not always safe and a number of concerns were identified at our inspection.” from the report
Incomplete care records
seriousRecords did not always show that people had been repositioned as planned or that bowel monitoring had been completed. Some care plans also lacked enough detail about people's current needs.
“This meant people's care records were not up to date to ensure people's care and health needs were appropriately managed.” from the report
Weak quality checks
seriousThe home's audits and action plans had not made sure that known problems were fixed. Several issues identified in earlier audits were still found during this inspection.
“The provider had not ensured robust systems were in place to identify where quality and or safety had been compromised.” from the report
Call bells
seriousSome people did not have a working call bell or could not use one. Inspectors found one person's bell was not working after the person had been waiting for help.
“We tried this person's call bell and found it was not working.” from the report
- 01What is the planned staffing level on each floor, and how will you ensure it is maintained during sickness, vacancies and staff breaks?
- 02What checks now make sure medicine stocks, instructions, allergy information and PRN guidance are accurate and up to date?
- 03How do you check that repositioning, bowel monitoring and other care tasks are completed and recorded as planned?
- 04What changes have been made to care plans so they give clear, personalised guidance about each person's current needs?
- 05How can residents and relatives raise concerns safely, and how do you check that complaints are handled consistently?
This was an unannounced comprehensive inspection covering all five key questions and providing ratings for the overall service and each question. This explanation was written from the published report of 21 June 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 Shelburne Lodge
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- August 2018Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2015Inspected but not ratedSafe: Requires improvement
- June 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 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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