CQC report explained · a residential care home
What the CQC found at Shenehom Housing Association
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe. Inspectors found clear risk assessments, safe recruitment, appropriate staffing arrangements, safe medicines administration and suitable infection control processes, although some emergency evacuation plans needed updating.
- Effective?
- Good
- People had their needs assessed and were supported with food, drink and healthcare. Some staff refresher training had been delayed during the pandemic, but the provider had an action plan.
- Caring?
- Good
- People described staff as respectful, kind, helpful and dependable. Staff supported people's faith, choices, dignity and independence.
- Responsive?
- Good
- Care plans were clear, detailed and updated to reflect changing needs. People were supported with activities, community involvement, relationships, communication needs and complaints.
- Well-led?
- Good
- People, relatives and staff spoke positively about the management and how the home was run. Inspectors recommended that the provider review its quality assurance systems so documentation was kept up to date.
What inspectors found, May 2022
Shenehom Housing Association is rated Good; inspectors found safe, kind and personalised care, with some records and staff training needing attention.
The unannounced inspection took place on 20 April 2022. Two inspectors spoke with people living at the home, staff, relatives and a professional. They also checked care plans, medicines, staff files, complaints, safeguarding, fire safety and quality records.
All five areas were rated Good. People said they felt safe and were treated with kindness and respect. Inspectors found clear risk assessments, safe medicines arrangements, personalised care plans, support with health needs, and activities that helped people stay independent and involved in the community.
There were some issues to keep under review. Some staff training and medicines competency checks needed updating. Personal emergency evacuation plans also needed updating, and the home was asked to review its quality audits so records stayed current. The provider took action on some records after the inspection and had a plan for refresher training.
People felt safe
People told inspectors they felt safe, and staff understood how to identify and report possible abuse. Risk assessments gave staff clear instructions for reducing risks.
“People told us they felt safe living at the service” from the report
Kind and respectful care
People said staff treated them with kindness and respect. Staff supported people's privacy, faith, choices and independence.
“People told us staff treated them with respect and kindness.” from the report
Personalised support
Care plans were detailed and tailored to people's needs and preferences. People were encouraged to take part in planning their care.
“Care plans were comprehensive, clear and concise and gave staff guidance on how to accurately meet people's needs.” from the report
Activities and independence
People were supported to use the community, take part in activities and develop daily living skills. Some people worked or volunteered.
“People were protected against social isolation and were encouraged and supported to access the community on a daily basis.” from the report
Good partnership working
The home worked with health and other professionals to support people's wellbeing and continuity of care.
“The provider worked alongside a range of other agencies and professionals to ensure continuity of care for the people they were supporting.” from the report
Quality records needed closer checking
needs fixingInspectors found that some medicines competency assessments and personal emergency evacuation plans needed updating. They recommended more detailed attention to audits and ongoing record keeping.
“We recommend the provider ensure quality assurance systems are regularly reviewed to ensure documentation is continually maintained and up to date.” from the report
Some staff training was out of date
needs fixingSome refresher training had been delayed because of the pandemic. The provider had an action plan, and inspectors said they would check progress at the next inspection.
“The provider had identified that some staff required updated training, this had been delayed due to the impact of the pandemic.” from the report
Building and pest control issues
minorSome parts of the home were dated and needed adapting. The home also had difficulties with pest control and had arranged to discuss this with the landlord.
“Some areas of the service were dated and required adaption.” from the report
- 01What staff refresher training is still outstanding, and when will it be completed?
- 02How do you now check that medicines competency assessments and personal emergency evacuation plans remain up to date?
- 03What changes have been made to the quality audits since the inspection?
- 04What is the current position on the dated areas of the building and the pest control problem?
- 05How are people and relatives involved in reviewing care plans and choosing activities?
This was an unannounced inspection based on the provider's previous rating; inspectors assessed all five key questions and also checked infection prevention and control under Safe. This explanation was written from the published report of 25 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, January 2018
Rated Good; inspectors found safe, kind and person-centred care across all five areas they assessed.
The inspection was unannounced and took place on 17 November 2017. One inspector spoke with people living in the home, staff, relatives and external professionals. They also observed care, checked records, medicines, policies and staff files.
The home supports up to 13 adults with mental health needs. Inspectors found people were safe, treated with kindness and supported to make choices and build independence. Medicines were managed safely, staffing levels were suitable, and care plans were detailed.
The home was rated Good overall and Good in Safe, Effective, Caring, Responsive and Well-led. This means the inspectors found the service continued to meet the regulations and fundamental standards. It had also been rated Good at the previous inspection in September 2015.
Safe medicines
People received their medicines as prescribed. Inspectors found the medicines records they checked were accurate and well managed.
“People received their medicines as prescribed by staff who had received appropriate training and guidance.” from the report
Promoting independence
The home balanced safety with people's freedom. Some people were supported to travel, work, attend activities and do things for themselves.
“The home's approach to risk assessment balanced with sound risk planning and management had enabled several residents go on holiday without staff support” from the report
Kind and respectful care
Inspectors saw staff treating people with respect, empathy and encouragement. Staff protected people's privacy by knocking before entering bedrooms.
“During the inspection we noted that people and staff had developed positive relationships, which were based on respect, empathy and encouragement.” from the report
Detailed care planning
Care plans covered health and personal care needs as well as people's preferences, aspirations, likes and dislikes.
“People's care plans were comprehensive and detailed.” from the report
Good oversight
The home used meetings, audits, care reviews and surveys to monitor the service and identify improvements.
“People received support from a service that routinely reviewed the care provision through regular audits.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you match staff to my relative's preferences, communication style and support needs?
- 02How do you support people to go out independently while managing identified risks?
- 03How will my relative be involved in care plan reviews and decisions about their support?
- 04What activities, work or courses could my relative take part in outside the home?
- 05How should we raise a concern or complaint, and how will you keep us informed of the outcome?
This was an unannounced inspection covering all five CQC questions and included observations, discussions with people, staff, relatives and professionals, and checks of care, medicines and other records. This explanation was written from the published report of 12 January 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.
Every inspection of Shenehom Housing Association
3 rated inspections over 7 years: the service has held its Good rating throughout.
- May 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Shenehom Housing Association →
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Shenehom Housing Association →
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 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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