CQC report explained · a nursing home
What the CQC found at Shipston Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and care plans reflected changes in people's needs. Medicines, infection control, safeguarding and the environment were managed safely, although some incident records had unexplained omissions and some people said help was sometimes delayed.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- Care plans were personalised and staff understood people's changing needs. Visiting was supported, complaints were investigated, and activities were available, but some people felt there was not enough to do and some concerns were not dealt with in a timely way.
- Well-led?
- Good
- Inspectors found stronger audits, meetings and oversight, with actions recorded on an improvement plan. Some food and fluid records still needed better documentation, and some people felt they had to find solutions when they raised concerns.
What inspectors found, December 2022
Shipston Lodge was rated Good; inspectors found improved safety, personalised care and stronger management, but noted delays in help, activities and some records.
This was an unannounced inspection visit on 09 November 2022. Inspectors spoke with people living at the home, relatives, staff and an outside professional. They also checked care records, medicines, staff files, safety checks, infection control and the home's quality systems.
The home was rated Good overall. Safe, Responsive and Well-led were rated Good. Inspectors found that care plans and risk assessments had improved, staff knew people well, medicines were managed safely and the home was clean. People and relatives were mostly positive about the care and the staff.
The inspection followed a Requires Improvement rating published in July 2021. Inspectors found positive changes, including a new registered manager, more audits, daily clinical meetings and better oversight. However, some people reported that help could take longer than expected, some felt there were not enough activities, and some records still needed to be more complete.
Personalised care plans
Care plans reflected people's individual needs, preferences and risks. Staff were able to describe and provide care that matched those plans.
“Care plans and risks assessments supported people's needs and plans were personalised to individual needs.” from the report
Kind and familiar staff
People and relatives were mostly positive about staff. Inspectors saw staff speaking with people at their pace, responding to them and spending time chatting.
“Staff interacted with people at their pace, unrushed and talking to people with familiarity.” from the report
Safe medicines and infection control
Staff received medicines training and competency checks. Inspectors were also assured that infection control arrangements, including PPE, were effective.
“We were assured that the provider was using PPE effectively and safely.” from the report
Better management oversight
The home had introduced more audits, daily handovers and regular meetings. Actions from audits were tracked through an improvement plan.
“These audits and checks were completed at regular intervals and actions were taken to drive improvement.” from the report
Family contact and community links
Families were welcomed, visiting was supported and technology was available when visits were not possible. The home also provided a dementia café and links with local groups.
“Families and external health visitors were welcomed and there were no restrictions on visiting arrangements.” from the report
Response times
needs fixingSome people and relatives said staff did not always respond as quickly as they wanted when assistance was needed. Inspectors did see staff respond to care bells during the visit.
“However, some people and relatives told us they thought staffing levels were not always ideal.” from the report
Activities
needs fixingThere was a programme of activities, including music, crafts and walks. However, several people felt there was not enough for them to do.
“There were regular activities organized which people attended set out by a weekly planner, but several people said to us they felt there was not enough for them to do.” from the report
Incomplete incident records
needs fixingIncident forms were not always completed consistently. Some contributing factors were missing, which could make it harder to understand why an incident happened.
“However, some incident forms were not always completed consistently with some unexplained omissions in 'contributing factors'.” from the report
Some information was not shared
needs fixingInformation about monitoring one person's ongoing health was missing from staff information. The home said it had taken action immediately after the inspection.
“However, some information that should have been shared about monitoring a person's ongoing health monitoring was missing.” from the report
Complaints and informal concerns
needs fixingAlthough complaints records showed investigations and responses, some people felt they had to find their own solutions or that responses were not always timely.
“Some people told us if they raised an issue, they felt it was up to them to find a solution.” from the report
Food and fluid records
minorInspectors found that some records did not clearly show exactly what people had consumed. The home said it had introduced improvements after the visit.
“During our visit, we some improvement to food and fluid charts required better documentation to show what exactly people had consumed.” from the report
- 01How quickly do staff respond when a resident uses their call bell, and how do you monitor any delays?
- 02How will you make sure there are enough activities for people with different interests and abilities?
- 03What changes have been made to food and fluid records, and how do you check that they are complete?
- 04How do you make sure incident forms include all contributing factors and that lessons are acted on?
- 05How are complaints and informal concerns followed up, and how will you show families what action was taken?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 6 December 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, July 2021
Rated Requires Improvement; inspectors found safe, kind care, but care records, choice and management checks were not always reliable.
This was the first inspection since the home was registered. Inspectors visited on 8 June 2021, spoke with people, staff and a health professional, and checked care, medicines, staff files and management records.
The home was rated Good for Safe, Effective and Caring. Inspectors found enough staff, safe medicines support, suitable training, good access to health professionals, and respectful care. Infection control measures were in place during the COVID-19 pandemic.
Responsive and Well-led were rated Requires Improvement. Some care records did not reflect changing needs, communication between nurses and care staff was not always clear, and people were not always supported to choose meals visually. Management checks had also missed some food storage, care record and privacy issues.
Enough staff
Inspectors found staffing levels met people's needs. People said staff responded without much delay and supported them in an unrushed way.
“There were enough staff on duty to meet people's needs.” from the report
Respectful care
Staff supported people kindly and at their own pace. Inspectors saw staff respect privacy, dignity and independence.
“Throughout the day, we saw staff were respectful which showed in their interactions with people.” from the report
Good health support
People were referred to health professionals when needed. Staff were described as quick to notice when someone needed help.
“They [staff] are very quick at picking up if you need help.” from the report
Infection control
The home had systems for preventing and managing infection during the pandemic. A local authority infection control audit gave a score of 99%.
“An Infection control audit completed by the local authority in April 2021, gave an audit score of 99%.” from the report
Care records and communication
needs fixingSome records did not keep pace with people's changing health needs. Staff also gave inconsistent accounts of how some people should be supported, which could affect their health.
“Care staff are not told enough about health concerns by nurses and issues raised are not always shared with carers by the nurses.” from the report
Meal choices
needs fixingPeople on the first floor were not supported to make a visual choice at mealtimes. This could limit their ability to choose a different meal or change their mind.
“People living on the first floor were not supported in making a visual choice at mealtime.” from the report
Food storage checks
needs fixingInspectors found undated food and almost all recorded fridge temperatures were above safe ranges. Existing audits had not identified or fixed this problem.
“We found almost all food fridge temperatures recorded in June 2021, exceeded safe temperature ranges.” from the report
- 01How will you make sure care plans and risk assessments are updated immediately when a person's health or mobility changes?
- 02How do nurses pass information about changing health needs to care staff at handover and during shifts?
- 03How are people supported to see and choose their meals, particularly people living on the first floor?
- 04How do you record and review ongoing consent for CCTV and photographs or videos used on social media?
- 05What checks now confirm that food is dated correctly and fridge temperatures stay within the required range?
This was a planned first inspection of the newly registered home covering all five key questions, including infection prevention and control; there was no previous rating to compare. This explanation was written from the published report of 22 July 2021 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 Shipston Lodge
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- December 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2021Requires improvementSafe: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2019
Registered with the Care Quality Commission on 23 August 2019.
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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