CQC report explained · a residential care home
What the CQC found at Shirlett Close
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 gaps in choking guidance, distress and incident records, food temperature checks and medicines management. There were enough staff to keep people safe, but staffing did not support people's social and emotional wellbeing.
- Effective?
- Requires improvement
- People had access to healthcare and staff training was up to date, but capacity assessments and best-interest decisions were not always recorded. People were not always supported to make choices or follow a varied diet.
- Caring?
- Requires improvement
- People appeared comfortable with staff and relatives praised the staff's caring nature. However, people were not always supported to make decisions, express their views or maintain their independence.
- Responsive?
- Requires improvement
- People had limited opportunities to leave the home, pursue interests, try new things or develop skills. Information was not always provided in ways people could understand, such as pictorial menus.
- Well-led?
- Requires improvement
- Managers were approachable and had started improvement work, but checks did not identify or fix important problems. Records did not consistently show people's involvement or that risks and incidents had been properly reviewed.
What inspectors found, June 2022
Rated Requires Improvement; inspectors found caring staff and some good systems, but people did not always receive safe, person-centred care.
This was the home’s first inspection since it registered with CQC under the current provider. One inspector visited without notice on 9 and 11 May 2022. They spoke with relatives, staff and healthcare professionals, observed care and checked care, medicine, recruitment and management records.
The home was rated Requires Improvement in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found risks and medicines were not always recorded or managed properly. People also had too few opportunities to go out, take part in activities, make choices and build independence.
There were some positive points. Staff knew people well, people had access to healthcare, the home was clean and infection control was satisfactory. Managers took some immediate action during the inspection and said they would increase staffing and improve activities and records.
Staff knew people
Staff understood people's safeguarding responsibilities and knew what action to take for one person's choking risk, despite gaps in the written guidance.
“Despite the gaps in written information, staff knew what action to take to keep this person safe.” from the report
Healthcare support
People had access to healthcare professionals, and a healthcare professional gave positive feedback about the manager's response to concerns.
“I have never had any concerns with the medical care.” from the report
Kind interactions
Inspectors saw some comforting and reassuring interactions. Relatives also described staff as caring.
“We saw some caring interactions between people and staff.” from the report
Clean environment
The home was described as safe and clean. Inspectors were assured that infection prevention arrangements were in place.
“People's care and support was provided in a safe and clean environment” from the report
Action had started
Managers accepted the findings and had begun making changes, including work on staffing, activities and documentation.
“Both managers had worked at the home for a considerable length of time and had started to implement actions to improve the service.” from the report
Limited activities and outings
needs fixingPeople had too few opportunities to leave the home, pursue interests or develop new skills. Staff did not always encourage activities recorded in people's care plans.
“People had limited opportunities to leave the service and pursue social interests within their local community.” from the report
Choice and independence
needs fixingPeople were not always involved in care decisions or given information in a way they could understand. Staff did not consistently encourage people to do things for themselves.
“People were not always involved in making decisions about their care.” from the report
Risk and incident records
seriousRecords did not always explain distress, possible triggers or staff responses. Some records about physical intervention were inaccurate.
“There was insufficient recording and reviewing of behaviours where a person had experienced distress.” from the report
Medicines and food safety
seriousSome medicine instructions were not followed on records, room temperatures were not recorded and creams were not always dated when opened. Cooked food temperatures had not been recorded since the beginning of the year.
“Improvements were needed to food safety standards. Staff had not recorded any cooked food temperatures since the beginning of the year.” from the report
Weak management checks
seriousThe home's monitoring systems did not identify or resolve several care, safety and record-keeping problems. This meant the service was not consistently providing high-quality, person-centred care.
“However, there was lack of effective oversight and governance which meant people had not received high quality, person centred care.” from the report
- 01What has changed to make sure people can go out regularly and take part in meaningful activities?
- 02How do you help each person understand choices about meals, care and daily activities?
- 03How are choking risks, distress and physical interventions now recorded, reviewed and shared with staff?
- 04How do you check that medicines are given as prescribed and stored at the correct temperature?
- 05What action plan did you send to CQC, and what evidence can you show of progress?
This was the first unannounced inspection of the newly registered service and covered all five CQC questions, including the care home and the personal care provided to people in their own homes. This explanation was written from the published report of 28 June 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.
Every inspection of Shirlett Close
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- June 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2019
Registered with the Care Quality Commission on 26 July 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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Most charge £950 to £1,260 a week. 80 can care for a couple. 11 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
“My mum would not eat, drink, bath nor sleep without her. In short, she was FAMILY and we loved her dearly”
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