CQC report explained · a residential care home
What the CQC found at The Shrubbery
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2021
Inspected but not rated; inspectors found strong COVID-19 infection controls but gaps in cleaning schedules.
This was an announced, targeted inspection on 17 December 2020. It looked only at infection prevention and control because the home had a coronavirus outbreak.
Inspectors were assured about visitor controls, social distancing, admissions, protective equipment, testing and outbreak management. People who had COVID-19 were supported by a staff member who did not have contact with others or enter the kitchen.
Inspectors found one shortfall. Cleaning schedules did not clearly show which areas needed cleaning or how often. The manager changed the schedules immediately after the inspection. The home was inspected but not rated, so this report does not give an overall quality rating.
COVID-19 support
People recovering from COVID-19 were offered food suited to changes in appetite and taste. This was intended to support weight gain where appropriate.
“Menus had been amended to help people recovering from COVID-19 regain their appetite.” from the report
Separating infection risks
People who had tested positive were supported by a staff member who did not work with other people or enter the kitchen.
“People who had tested positive for COVID-19 were supported by a staff member who didn't have contact with other people or enter the kitchen.” from the report
PPE and distancing
Staff were seen using protective equipment in line with guidance and distancing where possible. Staff breaks were arranged to support distancing.
“Staff were observed wearing Personal Protective Equipment (PPE) in line with guidance and were socially distancing where possible.” from the report
Isolation arrangements
Signs and PPE stations helped alert staff when people were isolating or had tested positive.
“PPE stations were situated outside the rooms of people who had tested positive for COVID-19.” from the report
Cleaning records
needs fixingCleaning schedules did not state the areas to be cleaned or how often. This meant the manager could not properly oversee the cleaning being done. The manager amended the schedules immediately after the inspection.
“cleaning schedules did not include the areas and frequency of cleaning required.” from the report
- 01What changes were made to the cleaning schedules after the inspection?
- 02How does the manager now check that all required areas are cleaned at the stated frequency?
- 03How are people who test positive for COVID-19 supported without staff having contact with other residents?
- 04How does the home manage PPE, testing and social distancing during an outbreak?
- 05How are menus adapted when residents are recovering from COVID-19 or have changes in appetite?
This was a targeted inspection of infection prevention and control during a coronavirus outbreak; it did not provide an overall rating or assess the wider quality of care. This explanation was written from the published report of 15 January 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, April 2018
Rated Good overall, but Safe was Requires Improvement because night staffing was not yet secure.
Inspectors carried out an unannounced comprehensive inspection on 8 February 2018. They spoke with people living at the home, relatives, staff and the manager. They observed care and checked care plans, risk assessments, medicines records, complaints, incidents and quality checks.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were all rated Good. People described kind and respectful care, choices over their daily lives, enjoyable meals and activities, and access to healthcare.
Safe was rated Requires Improvement. There were enough staff during the day, but the home was recruiting more night staff. Inspectors said the provider needed to show that night staffing was enough and that improvements would last. They also found some care records and daily notes needed more accurate recording.
The previous overall rating was Requires Improvement, with Safe rated Inadequate. Inspectors found improvements in the environment, mealtimes, activities and quality monitoring, but Safe remained Requires Improvement because the changes were not yet fully established.
Kind and respectful care
People said staff were kind, attentive and respectful. Staff asked about people's wishes and supported their privacy and independence.
“People we spoke with told us about living at the home and how the staff were kind, caring and attentive to them.” from the report
Improved mealtimes
People had choices of food and drinks, and staff supported those who needed help to eat and drink. Inspectors found mealtimes were more relaxed than at the previous inspection.
“At this inspection we found the service had made improvements with supporting people during their meal to have a relaxed and enjoyable experience.” from the report
Personalised support and activities
Care plans included people's life histories, preferences and care needs. People could choose activities such as singing, puzzles, games, cards and gardening.
“People were involved in planning their care and if requested their relatives were involved.” from the report
Better management checks
The home had audits covering care planning, people's needs, incidents and the environment. Action plans were used when checks found shortfalls.
“The service had a range of different measures in place to assess and monitor the quality and safety of all aspects of home life.” from the report
Night staffing was not yet secure
seriousThere were enough staff during the day, but inspectors found that more night staff were needed to respond to people's needs promptly. Recruitment was under way, but the provider still had to show that staffing would remain sufficient.
“We could not be assured that the improvements we found during this inspection were sustainable or sufficiently embedded into practice” from the report
Some records needed more accurate entries
needs fixingThe manager was updating care records and daily notes because the time of entries was not always recorded accurately. This was being addressed through the home's improvement work.
“the registered manager was in the process of updating people's care records and daily notes recording needed improvement to show a more accurate time of entry.” from the report
- 01Have the additional night staff now started, and how many staff are on duty overnight?
- 02How do you check that night staffing is enough for each person's needs, including urgent requests?
- 03How are care records and daily notes checked to make sure entries have accurate times?
- 04What evidence shows that the improvements made since the August 2017 inspection have continued?
- 05How will you involve my relative and our family in care planning, reviews and activities?
This was an unannounced comprehensive inspection covering the overall service and all five key questions, including care, the premises, records, medicines and quality checks. This explanation was written from the published report of 19 April 2018 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
4 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- January 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- April 2018Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Requires improvementup from InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2015
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- September 2011
Registered with the Care Quality Commission on 23 September 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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