CQC report explained · a residential care home
What the CQC found at Shepley House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found weaknesses in recruitment checks, staffing deployment, risk management, medicines management and some care records. People generally felt safe and the home was clean, but inspectors said there was an increased risk that people could be harmed.
- Effective?
- Good
- This key question was not inspected in this visit.
- Caring?
- Good
- This key question was not inspected in this visit.
- Responsive?
- Good
- This key question was not inspected in this visit.
- Well-led?
- Requires improvement
- Audits and checks did not identify important problems with care records, medicines and accidents. There was no registered manager in post, although families and staff spoke positively about the new manager.
What inspectors found, August 2023
Shepley House is rated Requires Improvement; inspectors found kind staff and clean premises, but safety and oversight systems were not reliable.
This was an unannounced inspection on 17 and 18 July 2023. Inspectors reviewed staffing, the building, care observations, five care records, four staff files, medicines records and the home’s management systems. They also spoke with people, relatives and staff.
Inspectors found problems with recruitment checks, staff deployment, risk records, pressure relief, food and drink support, medicines management and the handling of covert medicines. The home was clean, people generally felt safe, and many people and relatives spoke positively about staff. Families and staff also felt the new manager was making improvements.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The previous overall rating was Good in 2018, but this inspection found limited assurance about safety and an increased risk that people could be harmed. CQC will ask for an action plan and continue to monitor progress.
Kind and caring staff
People and relatives generally spoke positively about staff. Staff usually knew people well and were described as kind and caring.
“People spoke very positively about the staff employed at the home. Staff were described as kind and caring.” from the report
People felt safe
People said they felt safe being cared for, and relatives generally spoke highly about the support provided.
“People spoke very positively about staff support and felt safe being cared for at the service.” from the report
Clean environment and infection control
The home was clean and tidy. Inspectors were assured about the arrangements for preventing and managing infection.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Positive response from the new manager
Families and staff said the new manager was approachable and responsive. They felt improvements were already being made.
“It's much more organised now [manager] is here. We can always get hold of them.” from the report
Links with other organisations
The home worked with visiting professionals and community organisations. Inspectors saw people enjoy a music and movement group with young children.
“During the inspection we saw people living at the service attend a music and movement group with young children, which everyone in attendance appeared to enjoy.” from the report
Recruitment checks
seriousSome staff files did not show that references, employment gaps and conflicting information had been fully checked. This was a breach of Regulation 19.
“The provider had failed to ensure safe and robust recruitment processes were being followed.” from the report
Staff not always available
needs fixingStaff were not always positioned where people needed them. Inspectors saw delays with help to use the toilet, move around, receive pressure relief and eat meals.
“Staff were not always suitably deployed across the home to be available to support people in the various communal areas available for use.” from the report
Risk management and records
seriousMoving and handling was not always carried out safely. Records did not always clearly show people’s risks, care needs or whether planned support had been provided.
“People's moving and handling risks were not always safely managed.” from the report
Medicines management
seriousThere were problems with medicines storage, monitoring and records. Some covert medicines were given without the required best-interest process, least restrictive approach or pharmacist advice.
“Covert medicines were not being managed in line with best practice and the Mental Capacity Act (MCA).” from the report
Weak oversight
seriousThe home’s audits did not identify several problems found by inspectors. This was a breach of Regulation 17 on good governance.
“The provider had failed to embed robust systems for oversight to ensure best practice was followed, safety was effectively managed, and improvements made across the service.” from the report
Limited activities
minorWhen the activity worker post was vacant, people and relatives noticed less activity and stimulation. It was not clear how people who stayed in their bedrooms were supported.
“People and relatives told us they had noticed the absence of the activity worker and the impact of the lack of activities and stimulation when this post was vacant.” from the report
- 01How are you now checking references, employment gaps and reasons for leaving previous jobs before staff start?
- 02How do you make sure staff are visible and available across the home, including for pressure relief, toileting and help with meals?
- 03How are covert medicines now authorised, reviewed and recorded, including best-interest decisions and pharmacist advice?
- 04What checks now confirm that care records, falls, accidents and people’s changing risks are accurate and up to date?
- 05Who is responsible for the home while the manager completes the CQC registration process, and what actions from the inspection have been completed?
This was an unannounced inspection of Safe, including infection prevention and control, and Well-led; the other key-question ratings were carried over from the last inspection. This explanation was written from the published report of 16 August 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, November 2018
Shepley House is rated Good; inspectors found safe, kind and personalised care, with improvements made since the previous inspection.
This was an unannounced inspection over three days in August 2018. Inspectors spoke with people living in the home, relatives and staff. They observed care and mealtimes, and checked care plans, medicines records, staff files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer medicines systems, improved cleanliness and better support for people living with dementia.
The home had improved since the October 2016 inspection, when it had breached three regulations. Those breaches had been met by this inspection. Inspectors also found a warm atmosphere, detailed care plans, varied activities and stronger management oversight.
Previous problems addressed
The home had acted on the concerns from the 2016 inspection. Inspectors found that the earlier breaches had been met.
“At this inspection we found that the breaches identified had been met.” from the report
Medicines safety
The home had introduced electronic medicines records. The records checked showed that medicines had been recorded as given as prescribed.
“We saw that these records were fully completed to show that people had been given their medicines as prescribed.” from the report
Respectful care
Inspectors observed warm interactions and saw staff respect people's privacy, dignity and choices about when to get up.
“During the inspection we observed warm and friendly interactions between staff and people who used the service.” from the report
Activities and community links
People could take part in varied activities inside the home and in the local community. Their interests and suggestions helped shape the programme.
“We saw that there were a range of activities in place which included, tea dances, the Evening Owls Club, hand massages, animals visit such as a chinchilla dog and a donkey, wine and cheese evenings run by a local choir and trips out.” from the report
Detailed care planning
Care records included personal information about people's health, social care needs, character and preferences. This helped staff understand what mattered to each person.
“We noted these contained very detailed information regarding people's health and social care needs.” from the report
Management oversight
The registered manager and external managers carried out regular checks. Inspectors found that the manager was committed to continuing improvements.
“We saw copies of recent 'manager action checklists' carried out by external managers to the home.” from the report
One disorganised mealtime
needs fixingOn the first inspection day, an agency cook did not know who needed a special diet. Inspectors also saw people waiting for food, which was particularly stressful for some people living with dementia. Regular chefs later confirmed they knew about special dietary needs.
“On the first day of our inspection we found that the service had an agency cook in place who told us that they did not know who was on special diets.” from the report
Some mixed views about staff
minorMost feedback about staff was positive, but one person said some staff were unkind and in a hurry. This is worth checking when visiting and speaking with the home.
“Some staff are kind some are not. They are always in a hurry.” from the report
Recruitment paperwork
minorThe staff files checked contained employment histories, but one application needed to be amended to show a full employment history.
“The application needed to be amended to show a full employment history.” from the report
- 01How do you make sure agency or temporary kitchen staff know which people need special diets?
- 02What action was taken after the disorganised mealtime observed during the inspection?
- 03How will the ongoing refurbishment improve the environment for people living with dementia?
- 04How do you check that all staff consistently treat people kindly and do not rush their care?
- 05How are people's views, complaints and activity requests recorded and followed up?
This was an unannounced inspection of the overall quality of the home, covering all five CQC questions and providing an overall rating. This explanation was written from the published report of 1 November 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 Shepley House
3 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- January 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 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 18 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Stockport
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 88 can care for a couple. 10 years' experience on average.
“Primrose is a very kind and compassionate healthcare professional”
“She is an exemplary carer, she is knowledgable empathetic and very respectful in the home.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.