CQC report explained · a nursing home
What the CQC found at Shirelodge Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found risks were assessed and reviewed, medicines were managed safely, infection control measures were followed and there were enough trained staff. Some call bells were not initially within reach, but the manager acted immediately.
- Effective?
- Requires improvement
- Mental capacity assessments were not always decision-specific, and records did not always show best-interests decisions. One person at risk of malnutrition did not have food and fluid intake monitored closely enough.
- Caring?
- Good
- This key question was not inspected during this focused visit, so the report does not give a current rating here.
- Responsive?
- Good
- This key question was not inspected during this focused visit, so the report does not give a current rating here.
- Well-led?
- Good
- Management oversight, quality monitoring and accident and incident reviews had improved. The manager acted on issues, sent required notifications and worked with health and social care professionals.
What inspectors found, January 2022
Rated Good overall; inspectors found safe care and stronger leadership, but records about capacity decisions and nutrition still needed improvement.
This was an unannounced, focused inspection on 13 December 2021. Inspectors checked whether the home had improved its management of falls, accidents, incidents and quality monitoring. They also checked infection prevention measures.
The home was rated Good overall. Safe and well-led were rated Good. Inspectors found enough staff, safe medicine systems, improved incident monitoring and suitable infection control. People and relatives generally said they felt safe and involved in care.
Effective was rated Requires Improvement. Mental capacity assessments were not always specific to the decision, and records did not always show best-interests decisions. One person at risk of malnutrition did not have food and fluid intake monitored closely enough, although the manager acted during the inspection.
The previous overall rating was Requires Improvement, with breaches of Regulations 12 and 17. Inspectors found enough improvement at this visit and said the home was no longer in breach. Caring and Responsive were not inspected during this focused visit, so their previous ratings were used in calculating the overall rating.
Improved safety systems
Risk assessments were reviewed as people's needs changed. Accident and incident monitoring had improved so the home could identify patterns and reduce repeat incidents.
“The systems to monitor accidents and incidents had been reviewed and improved.” from the report
Enough staff
Inspectors found enough staff to meet people's needs safely. Recruitment checks, including references and DBS checks, were completed before new staff started.
“There were enough staff available to ensure people's needs were met safely.” from the report
Safe medicines and infection control
Medicines were stored securely and staff were trained and assessed as competent. Inspectors were assured that the home was using infection control measures and supporting safe visits.
“All medicines were stored securely.” from the report
Stronger management oversight
The home had improved its quality monitoring and acted when problems were found. People, relatives and staff described the manager as approachable and making a positive difference.
“The quality of the management oversight had improved, monitoring of documentation relating to the safety of people was reviewed consistently and action taken appropriately when issues were found.” from the report
Capacity and best-interests records
needs fixingCapacity assessments were not always specific to the decision. Records did not always show that best-interests decisions had been made, including decisions about giving some medicines covertly.
“Mental capacity assessments were completed, however, they were not always decision specific.” from the report
Monitoring food and fluids
needs fixingOne person at risk of malnutrition did not have food and fluid intake monitored closely enough. The manager changed the electronic recording system during the inspection so shortfalls would be flagged.
“This had not been identified in the audit process.” from the report
- 01How do you now make sure every Mental Capacity Assessment is specific to the decision being made?
- 02How do you record and review best-interests decisions, including decisions about covert medicines?
- 03How do you identify and respond when a resident is not eating or drinking enough?
- 04What checks make sure call bells are within reach for every resident who may need help?
- 05What were the previous ratings for Caring and Responsive, and when will these areas next be assessed?
This was an unannounced focused inspection of Safe, Effective and Well-led, mainly following up imposed conditions about falls, incidents and quality monitoring; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 25 January 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, May 2021
Rated Requires Improvement; inspectors found kind, person-centred care, but risks and oversight were not managed well.
This was an unannounced, planned inspection on 13 and 16 January 2020. Inspectors spoke with people living there, relatives and staff. They observed care and checked care plans, medicines records, staff files and management records.
The home was not always safe or effective. Risk assessments were not always followed. There were problems with falls prevention, incident records, a fire door and the condition of some bedrooms. Inspectors also found that quality checks had not identified or acted on these issues.
People were treated with kindness and respect. Care plans were personalised and regularly reviewed. People were supported with activities, communication, complaints and end of life wishes. Medicines, infection control, staffing and staff training were generally managed well.
The overall rating was Requires Improvement. Safe, Effective and Well-led were also Requires Improvement, while Caring and Responsive were Good. The home had received Requires Improvement at the previous inspection and had held this rating for two consecutive inspections.
Kind and respectful care
People received care from staff they knew. Staff protected privacy and dignity and encouraged people to remain independent.
“People received care from staff they knew and thought the staff were kind and caring.” from the report
Personalised care planning
People and relatives were involved in creating and reviewing care plans. Plans included personal preferences, cultural needs and health requirements.
“Care plans were detailed and personalised. They were regularly reviewed, and changes made as appropriate.” from the report
Medicines and infection control
Inspectors found that medicines were given safely and that staff had suitable infection control equipment and training.
“People received their medicines safely. They told us they had their medicines on time.” from the report
Risks were not consistently managed
seriousRisk assessments were not always followed. This included a missing low profiling bed and bed rails being used when the assessment said they should not be.
“The provider failed to ensure risks were managed and mitigated.” from the report
Falls and incidents were not always followed up
seriousAccident and incident forms were not always completed. Some people with repeated falls had not been referred promptly to the NHS falls prevention team.
“Accident/incident forms were not always completed, and this resulted in not all incidents being investigated and measures put in place to reduce risks.” from the report
Some parts of the building needed repair
needs fixingSeveral bedrooms had furniture and flooring that needed replacing. A fire door also had a large gap underneath.
“Some bedrooms were in a poor state of repair. Furniture and flooring required replacing in multiple rooms.” from the report
Quality checks were not effective
seriousThe home's monitoring systems had not identified important problems. A daily management walkaround was not always completed, partly because the manager was covering care shifts.
“Not enough improvement had been made at this inspection and the provider was still in breach of regulation 17.” from the report
- 01What has been done since the inspection to ensure every risk assessment is followed, especially for falls and bed rails?
- 02How are accidents and incidents now recorded, investigated and used to reduce further risks?
- 03Have all bedroom repairs, furniture and flooring replacements, and the fire door repair been completed?
- 04How are monthly action plans for Regulations 12 and 17 being monitored, and can families see the progress?
- 05How are people referred to falls prevention or other specialist teams when their needs increase?
This was an unannounced, planned inspection covering all five CQC questions, including the care provided and the home environment. This explanation was written from the published report of 22 May 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 Shirelodge Nursing Home
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- January 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- May 2021Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not rated
- January 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017
Registered with the Care Quality Commission on 5 October 2017.
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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