Archived: Shenleybury House Limited

Updated 14 May 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was completed by one inspector.

Service and service type

Shenleybury House Limited is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Shenleybury House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 28 February 2022 and ended on 04 April 2022. We visited the service on 28 February 2022.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with two people who used the service about their experience of the care provided and received feedback from five relatives. We spoke with five members of staff including the provider representative, registered manager and care staff. We also received written feedback from five members of staff

We reviewed a range of records. This included two people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including audits and monitoring records, were also reviewed.

Updated 14 May 2022

About the service

Shenleybury House Limited is a care home registered to provide accommodation and personal care to up to 15 older people. At the time of our inspection there were 10 people living at the service.

People’s experience of using this service and what we found

People and their relatives told us they felt safe. Staff had received training in safeguarding and felt confident in reporting any concerns. Risks to people’s health, safety and wellbeing had been identified and staff were aware of the action they needed to take to help keep people safe.

Staff were attentive and able to respond promptly to people. The registered manager monitored staff deployment and ensured enough staff were on duty at all times. Staff recruitment was safe and pre-employment checks completed.

Medicines were managed safely and regular audits completed. We were assured by the measures taken to help ensure the prevention and control of infection.

People’s needs and choices were assessed before admission to the service and they were asked to express their views and decisions about their care. Care records showed that people, and their relatives where applicable, were involved in their development and review. Care provided was personalised and considered people’s preferences and wishes.

People were supported by caring, friendly staff who knew their needs well. Staff were trained and felt supported in their roles. People and their relatives described care staff as knowledgeable and skilled and felt that privacy and dignity was maintained and promoted throughout the care provided.

People’s health needs were being met. The service worked closely with health professionals and staff made referrals to external agencies when they identified any changes in people’s health and wellbeing.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People, relatives and staff spoke positively about the management of the service and their openness to feedback. We were told the registered manager was approachable, maintained regular communication and listened to the views of others. The service had a development plan in place which detailed any actions identified in the range of quality assurance processes in place. The registered manager actively sought feedback to monitor and improve safety at the service and the quality of care provided.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 30 January 2021).

The provider completed an action plan after the last comprehensive inspection (published 22 August 2020) to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last comprehensive inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Shenleybury House Limited on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.