CQC report explained · a residential care home
What the CQC found at The Shrubbery Rest Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks such as falls, personal care needs and behaviours were assessed and managed. Medicines, staffing, fire safety and infection-control arrangements had improved, although inspectors saw some shortcomings in mask wearing and jewellery.
- Effective?
- Good
- This area was not assessed as part of this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This area was not assessed as part of this focused inspection. Its previous rating was carried forward.
- Responsive?
- Good
- This area was not assessed as part of this focused inspection. Its previous rating was carried forward.
- Well-led?
- Good
- Quality checks had become more effective, care records had improved, and people, relatives and staff had opportunities to give their views. The provider was no longer in breach of good governance requirements.
What inspectors found, October 2021
Rated Good; inspectors found major improvements in safety and management, with a few infection-control issues still needing attention.
Inspectors visited the home without notice on 14 September 2021. They spoke with people, relatives and staff, observed care, and checked care records, medicine records, training records and quality checks.
They found that risks were being assessed and managed more effectively. Medicines were given safely, staffing levels had improved, staff recruitment and training were suitable, and care records contained more useful personal information. Infection-control arrangements had also improved.
This was a focused inspection of Safe and Well-led. Both were rated Good. The overall rating changed from Requires Improvement to Good because the provider had addressed the earlier problems and was no longer in breach of the regulations checked.
Better risk management
Risks were assessed and care plans gave staff clearer instructions about how to reduce them. Falls were followed up and accident records were reviewed for patterns.
“Care plans contained information for staff about how to manage and mitigate risks to people.” from the report
Safe medicines
Medicine records were complete, stocks matched the records, and medicines were stored securely and at safe temperatures.
“People's medication administration records (MAR) had been fully completed and medicine stocks tallied with the records maintained.” from the report
Enough staff and suitable training
Inspectors found a good staff presence and no concerns about staffing levels. Recruitment checks, training and supervision had improved.
“The provider had taken action to ensure staff were appropriately trained and skilled in their role.” from the report
Stronger management checks
New quality monitoring systems were identifying shortfalls and tracking action to address them. A deputy manager had also been appointed to support the registered manager.
“A recent quality monitoring report showed that action had been taken to address shortfalls identified at the previous audit.” from the report
More personal care records
Care plans included people's preferences, social history, religious preferences and important relationships. People and relatives were involved in planning and reviewing care.
“People's care plans contained information about their likes, dislikes, how they wanted to be supported and information about their social history, religious preferences and the important people in their lives.” from the report
Infection-control practice
minorOne staff member wore a mask under the chin and some staff wore rings. Inspectors said this increased the risk of infection spreading, and the provider said it would address the issue.
“One member of staff was seen wearing their face mask under their chin. Some staff were seen to be wearing stoned rings.” from the report
Limescale in the bath
minorInspectors found limescale on the base of a walk-in bath. The provider said the bath would be replaced.
“A walk in bath had limescale on the base, however the provider informed us this was to be replaced.” from the report
- 01What action was taken about staff wearing masks under the chin and wearing rings?
- 02Has the walk-in bath with limescale been replaced, and how is its cleanliness now checked?
- 03How are falls and other accidents recorded, reviewed and followed up?
- 04How often are medicine records and medicine storage audited?
- 05How will you make sure the improvements made after the previous inspection continue?
This was a focused inspection of Safe and Well-led, with infection control also checked; the other key-question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 12 October 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.
What inspectors found, July 2021
Rated Requires Improvement overall, with Safe rated Inadequate because of risks, medicines, infection control and staffing concerns.
This was an unannounced focused inspection after anonymous concerns were received. Inspectors looked at Safe and Well-led. They spoke with people, staff and relatives, observed communal areas and checked care, medicines, staffing and management records.
Inspectors found that people were not always protected from avoidable harm. Risks were not always assessed or reviewed after incidents. Some medicines had been missed or were not stored safely. Infection control guidance was not always followed, and communal areas were sometimes left without enough staff supervision.
The home was rated Inadequate for Safe and Requires Improvement for Well-led. The overall rating fell from Good at the previous inspection. The ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection and were not assessed during this visit.
Safe recruitment
Staff recruitment checks were carried out, including employment history, references and criminal record checks. Risk assessments were used while some references were outstanding.
“Staff were recruited safely. Checks were made on staff members suitability, such as employment history, references and criminal convictions.” from the report
Safeguarding awareness
Staff understood different types of abuse, the signs to look for and how to report concerns. Referrals were made to the local safeguarding authority.
“Staff understood their safeguarding responsibilities. They were aware of different types of abuse, understood the signs to look for and knew to report their concerns” from the report
Response to feedback
The provider and manager made improvements after inspectors explained their concerns. Other organisations later found that the concerns had generally been acted on.
“Whilst there had been failures in safety, the provider and registered manager had been extremely proactive in responding to feedback and making necessary improvements.” from the report
Approachable leadership
People and staff spoke positively about the provider and manager and said they felt supported and able to approach them.
“People and staff were complimentary of the registered manager and provider.” from the report
Medicines
seriousSome people missed doses, records had gaps and stock levels did not match. Medicines were not always stored at a verified safe temperature.
“Some people had missed doses of medicine and this had not been addressed, such as seeking medical advice, at the time of the error.” from the report
Risks and incidents
seriousCare plans were not always updated after falls, anxiety or other incidents. Checks after falls and referrals to health professionals were not always recorded or made promptly.
“Risks were not always fully assessed and planned for and lessons were not always learned when there had been accidents or incidents in the home.” from the report
Staff supervision
seriousCommunal areas were often difficult to supervise, and incidents such as falls were frequently unwitnessed. Some people also said staff response could be slow or rushed.
“Incidents were frequently unwitnessed by staff in communal areas, such as falls and incidents between people.” from the report
Records and quality checks
needs fixingThe home's audits and care plan reviews did not reliably find inaccurate or missing information. Some care plans contained incorrect details or referred to other people.
“Care plans contained inaccurate information, such as details of health conditions the person did not have, or they referenced other people's names” from the report
- 01What checks now ensure that medicines are given as prescribed, stock levels are correct and storage temperatures are recorded?
- 02How are falls, anxiety and other incidents now reviewed, and how do you make sure care plans and referrals are updated afterwards?
- 03How do you ensure communal areas are supervised and there are enough staff available when people need help?
- 04What has changed in cleaning, staff testing and temperature checks since the inspection?
- 05How are inaccurate care plans and missing records now identified and corrected through quality audits?
This was an unannounced focused inspection of Safe and Well-led only; ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 25 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 The Shrubbery Rest Home
6 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- October 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2021Requires improvementdown from GoodSafe: InadequateWell-led: Requires improvement
- January 2021Goodstayed GoodSafe: GoodWell-led: Good
- January 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- December 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- March 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016
Registered with the Care Quality Commission on 1 April 2016.
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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