CQC report explained · a residential care home
What the CQC found at Shenley Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People and relatives said they felt safe. Risks, medicines, staffing, recruitment and infection control were managed safely. Inspectors noted that the fire risk assessment should be completed by a competent person.
- Effective?
- Good
- Care plans were detailed and kept up to date. Staff had relevant training and support, and people received help with food, drink, healthcare and decisions made under the Mental Capacity Act.
- Caring?
- Good
- Staff treated people with kindness, respect and compassion. People were involved in decisions, had privacy and were encouraged to do as much as possible for themselves.
- Responsive?
- Good
- Care was personalised to people's likes, dislikes, communication needs and daily choices. People were supported with activities, visits and contact with loved ones.
- Well-led?
- Good
- The home had a positive and supportive culture. Quality checks covered medicines, health and safety and care, and the manager worked with health and social care professionals.
What inspectors found, February 2022
Rated Good; inspectors found safe, kind and personalised care, with fire safety assessment arrangements needing attention.
Inspectors made an unannounced visit on 14 December 2021. They spoke with people living at the home, relatives and staff. They observed care and checked care plans, medicine records, staff files and quality checks.
The home supports up to seven people with learning disabilities. Six people were living there at the time. Inspectors found that people were safe, treated with kindness and supported to make choices and be as independent as possible.
The inspection was prompted by concerns about medicines, staffing, training, choice, dignity, nutrition and hydration. Inspectors found no evidence that people were at risk of harm from these concerns. All five areas were rated Good, which means the service was meeting the CQC's standards at the time of the inspection.
Choice and independence
People were supported to make day-to-day decisions and to do things for themselves. Their care was based on their individual wishes and abilities.
“The model of care and setting maximised people's choice, control and independence.” from the report
Kind and respectful staff
Inspectors observed staff speaking respectfully and taking time to engage with people. Relatives described staff as compassionate and understanding.
“People received kind and compassionate care from staff who used positive and respectful language.” from the report
Safe medicines support
Medicines were securely stored, checked and recorded. Staff had medicines training and regular checks of their competence.
“Medicines were managed safely. There were clear processes for ordering, administration and disposal of medicines.” from the report
Personalised communication and activities
The home used information in formats people could understand and supported people to follow their interests and keep in touch with relatives.
“Staff ensured people had access to information in formats they could understand.” from the report
Supportive leadership
Staff said they felt supported and valued. The home had systems for checking the quality and safety of care.
“There were quality assurance and governance systems in place.” from the report
Fire risk assessment
needs fixingThe fire risk assessment had been completed by the registered manager rather than a competent person. After the inspection, the home said it was seeking advice from a professional fire risk assessor.
“We discussed with the registered manager that fire risk assessments must be completed by a competent person.” from the report
- 01Has a professional fire risk assessor now reviewed the home's fire safety procedures?
- 02How will you support my relative to make their own choices and remain as independent as possible?
- 03How will you communicate with my relative in the formats and ways they understand best?
- 04How will you keep my relative's care plan and risk assessments updated when their needs change?
- 05How will you involve our family in care reviews and decisions about healthcare and daily support?
This inspection examined concerns about medicines, staffing, training, choice, dignity, nutrition and hydration, and also assessed all five key questions, including infection prevention and control. This explanation was written from the published report of 3 February 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, September 2018
Rated Good; inspectors found kind, safe and person-centred care, but financial records and formal complaint responses needed improvement.
This was an announced inspection on 21 August 2018. One inspector visited, spoke with people, relatives, staff and professionals, and checked care files, staff records, medicines, finances and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, safe medicines practice, suitable risk assessments, clean surroundings and care that respected people's choices, dignity and independence.
There were two areas needing attention. Records and checks for people's money were not reliable, creating a risk of financial abuse. Complaints were investigated, but the home had not always sent the formal response required by its own policy.
At the previous inspection in December 2015, the home had been rated Good but had breached safeguarding rules. Inspectors said satisfactory action had been taken in response, and they found improvements in the use of Deprivation of Liberty Safeguards.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs. Medicines were securely stored, administered as prescribed and accurately recorded.
“Medicines were recorded and administered safely.” from the report
Kind and respectful care
People were treated with kindness and dignity. Staff knew people's preferences and encouraged them to do things for themselves.
“Throughout the day we saw staff sitting with people engaging in conversation with laughter and kindness.” from the report
Individual support
Care plans gave detailed guidance about people's routines, communication, dietary needs and preferences. Staff showed a good understanding of these plans.
“Detailed care records enabled staff to have a good understanding of each person's needs and how they wanted to receive their care.” from the report
Activities and inclusion
People could take part in a wide range of activities and were supported with cultural, religious and personal needs.
“The activities were being run with kindness and sensitivity, involving everyone who wanted to participate.” from the report
Supportive management
Staff said the registered manager was approachable and supportive. The home held staff and house meetings and used several monitoring systems.
“Staff told us that they felt supported by the registered manager.” from the report
People's money
seriousFinancial records did not always match the money held for people. Inspectors said this created a risk of potential financial abuse and recommended getting advice to improve the system.
“This meant people were at risk of potential financial abuse.” from the report
Complaint responses
needs fixingComplaints were investigated and the home worked towards resolving them, but it did not formally respond as its complaints policy said it would.
“The service had documented the details and outcomes of the complaints however they did not provide a formal response as stated in their complaints policy.” from the report
Quality checks missed finance errors
needs fixingThe provider's July 2018 check did not identify the financial recording problem found during the inspection.
“However, we noted financial transactions were not robust during our inspection and this was not highlighted in the provider's last check for July 2018.” from the report
- 01What new system is now used to check people's money and match balances with the records?
- 02How are financial discrepancies reported, investigated and corrected?
- 03How will you make sure every complaint receives the formal response promised in the complaints policy?
- 04How do you check that the improvements made since the previous safeguarding breach remain effective?
- 05How are relatives invited to take part in annual care reviews?
This was an announced inspection of the overall service, covering all five CQC questions, the care provided and the home environment. This explanation was written from the published report of 18 September 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 Shenley Lodge
3 rated inspections over 6 years: the service has held its Good rating throughout.
- February 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 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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