CQC report explained · a residential care home
What the CQC found at 43 Shirley Gardens
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
Support for Living Limited - 43 Shirley Gardens: Rated Good; inspectors found safe, kind and personalised care, with one medicines recording error.
The inspection was unannounced and took place on 28 September 2023. One inspector and an Expert by Experience spoke with five people, four staff and three relatives. They reviewed care records, staff records and management checks.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found suitable risk assessments, trained staff, personalised care plans, good support with healthcare and positive relationships between people and staff.
There was one medicines recording discrepancy for one medicine. The manager investigated and corrected it straight away. The home was also not providing end of life care at the time, and the related form had few details recorded.
The previous rating was Good, published in September 2017, and all ratings remained Good. No breaches of regulations or enforcement action were reported.
Personalised support
Care plans included people's needs, preferences and communication requirements. People were involved in planning and reviewing their support.
“People were supported as individuals, in line with their needs and preferences.” from the report
Choice and independence
People could make everyday choices, go out independently where appropriate and choose when and where to eat. Staff supported people when they needed help.
“Everyone could eat independently and could choose where they wanted to eat and when.” from the report
Kind relationships
People described staff as kind and said staff listened to them. Inspectors observed positive interactions and found that dignity and independence were respected.
“People told us staff listened to them and acted upon what they had to say.” from the report
Activities and relationships
People were supported to keep in touch with family and friends and to take part in activities such as outings, shopping, meals out and places of worship.
“People using the service were able to go out independently, but if needed, staff provided support and accompanied people.” from the report
Clean and safe environment
The home was clean and tidy. Fire, environmental and emergency arrangements were checked, with action plans where needed.
“On the day of inspection, the home was clean and tidy and a cleaning schedule was in place.” from the report
Medicines recording error
needs fixingInspectors found a mismatch between the records and the stock for one medicine. The manager investigated immediately and corrected the records, but families should ask how medicines checks prevent this happening again.
“However, during the inspection we identified a discrepancy between the medicines administration records (MARs) and the stock for one medicine.” from the report
Limited end of life details
minorThe home was not providing end of life care during the inspection. Its discussion form had few details recorded, although the manager said people had been asked about their wishes and were not ready to discuss them in detail.
“The provider had a form to help discussion in this area but there were few details recorded.” from the report
- 01What checks are now in place to make sure medicines administration records match the medicine stock?
- 02What happened after the medicines discrepancy, and how was learning shared with staff?
- 03How would you record and review my relative's end of life wishes if they wanted to discuss them?
- 04How often would my relative's care plan and preferences be reviewed?
- 05What activities and support would be available to help my relative maintain relationships and independence?
This was an unannounced inspection covering all five CQC questions, with evidence from people, staff, relatives, care records, staff records and management checks. This explanation was written from the published report of 17 November 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, March 2022
Support for Living Limited - 43 Shirley Gardens was inspected but not rated; inspectors found good infection control, with one staff risk assessment needing more detail.
This was an announced, targeted inspection on 11 February 2022. Inspectors gave 24 hours' notice and looked mainly at infection prevention, visiting arrangements and the effect of COVID-19 staffing pressures.
The home supported six people and had space for seven. Inspectors found good arrangements for visitors, testing, vaccinations, personal protective equipment, social distancing, ventilation and cleaning.
The provider had measures to manage COVID-19 staffing pressures. Inspectors also discussed making staff risk assessments more detailed, including separate assessments for each staff member and risk indicators such as age and ethnicity.
The service was inspected but not rated. This means the report does not give a quality rating for the home, and it should not be read as a full assessment of all areas of care.
Visitor safety
The home had checks and procedures to reduce the risk of infection from visitors. This included COVID-19 questions, testing and vaccination evidence where required.
“The provider had clear procedures for visitors to help ensure infection was controlled and prevented.” from the report
Protective equipment
Staff and visitors used personal protective equipment properly. Staff had infection control training, and checks were carried out each day.
“Staff and visitors wore and disposed of personal protective equipment (PPE) appropriately.” from the report
Testing and response
People living in the home and staff took part in regular testing. The home followed guidance when people tested positive and shared information with relevant services.
“The provider responded appropriately to people with positive test results.” from the report
Clean environment
Inspectors found the home clean. Cleaning records were checked and audited monthly.
“Cleaning schedules recorded when cleaning had taken place and were audited monthly to help maintain a good standard of cleanliness and help reduce the risk of infection.” from the report
Staff risk assessments
minorThe staff COVID-19 risk assessment was general rather than completed for each staff member. Inspectors discussed adding risk indicators such as age and ethnicity.
“However, the staff risk assessment was general and we discussed with the provider adding in risk indicators such as age and ethnicity and completing one for each of the five staff.” from the report
- 01Have individual COVID-19 risk assessments now been completed for each staff member?
- 02How were age and ethnicity included in staff risk assessments after the inspection?
- 03How are current visiting, testing and vaccination procedures explained to families?
- 04How does the home respond when a resident or staff member tests positive for COVID-19?
- 05How are cleaning schedules checked and acted on if a problem is found?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 3 March 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 43 Shirley Gardens
3 rated inspections over 8 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2022Inspected but not ratedSafe: Inspected but not rated
- September 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 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 21 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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