Shepley House

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

Systems to ensure people were safe were not always being used effectively and people’s needs, and risks were not always readily identifiable in care records. Staff were not always recruited in line with safe recruitment policies and feedback about staff and their visibility within the home was mixed. We have made a recommendation about this. Medicines were not always managed in line with good practice in relation to storage and medicines people were being given covertly, hidden in food or drink. We have made a recommendation about this. Details about how to manage risk was not always clear and records did not demonstrate that people’s assessed needs were being met. We have made a recommendation about this.

Records of accidents and incidents were not always identified in the systems for oversight but, when identified appropriate action was being taken. The service was clean and tidy, and people were encouraged to receive visits from friends and family. People felt safe and relatives generally spoke highly about staff.

People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support good this practice.

There was no registered manager in post, and we found the service had not submitted a notification of a serious injury to CQC in a timely way. Systems for oversight were not always used effectively as areas for improvement we identify such as medicines, and accidents had not been identified. Families and staff spoke highly of the new manager and felt confident to raise concerns with them. Staff and families felt improvements were being made within the service.

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 good (published 31 October 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and Recommendations

We have identified breaches in relation to the recruitment of staff and the systems for oversight in place to ensure the service was safe.

We have made recommendations about the systems in place for the monitoring and management of risk staffing deployment and training and management of medicines administration.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The service was last inspected in October 2016 when we found Shepley House was in breach of three regulations. These related to the safety of medicines management, control of substances hazardous to health, use of equipment, staffing levels and good governance. We also made two recommendations in relation to respecting people’s belongings and Deprivation of Liberty Safeguarding (DoLS) authorisations. At this inspection we found that the breaches identified had been met.

Shepley House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Shepley House is registered to provide accommodation for up to 43 people who require support with personal care.

There was a registered manager in place at Shepley House. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was present during the inspection. They were supported in the day to day running of the service by two deputy managers.

Improvements had been made to the systems in place to ensure the safe handling of medicines.

Improvements had been to the cleanliness of the environment and systems were also in place to reduce the risk of cross infection in the service.

Staff had received training in safeguarding adults. They could tell us of the action they would take to protect people who used the service from the risk of abuse. They told us they would be confident to use the whistleblowing procedure in the service to report any poor practice they might observe. They told us they were certain any concerns would be taken seriously by the registered manager.

Systems were in place to ensure staff were safely recruited. Staff told us they received the training and supervision they needed to be able to carry out their roles effectively.

The registered manager had taken appropriate action to apply to lawfully restrict people and where necessary decisions were made in people’s best interests.

Improvements had been made to the home including making it more friendly for people who lived with dementia.

People and relatives spoke positively about the staff and the atmosphere at the home was warm, friendly, calm and relaxed.

Care plans were in place to help ensure staff provided the level of support necessary to manage the identified risks. Care plans were regularly reviewed to address any changes in a person’s needs.

We saw that the home was part of an activities group. The activities co-ordinator was enthusiastic about their role and was supported by a small number of volunteers and the staff team to carry them out. The home was working hard to maintain and develop links with the local community.

People who used the service had opportunities to comment on the support they received. We saw that their views had been taken seriously and acted upon in order to improve their experience in the service.

We found improvements had been made to the staff culture at the home to help ensure people received person-centred care to meet their individual needs.

We found the registered manager demonstrated a commitment to continuing to drive forward further improvements in the service.

Staff we spoke with told us they enjoyed working in the service and felt valued by both colleagues and the registered manager.

Quality assurance systems were in place including regular audits and checks completed by the registered manager and an external management.

Shepley House is situated in a residential area of Hazel Grove in Stockport. It is a purpose built with accommodation spread over two floors. The home is registered to provide accommodation and personal care for up to 43 people. At the time of the inspection, 42 people were living at the service, some of whom were living with a dementia related condition. Some bedrooms have ensuite facilities. There are communal areas, including a range of lounges, dining areas and a large garden for people to use which has a summer house situated at the centre and is used for a variety of activities. The provider informed us that the service is earmarked for a major transformation/refurbishment by the local authority, who owns the building, by the end of 2020.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found concerns with the safe administration of medicines. Staff did not always follow safe working practices or followed correct procedures. For example, we saw two staff members in different parts of the service administer medicines to people without waiting to check they had taken their medicines. When we checked people’s records we found that no person at the service self-administered medicines, so this should not have occurred. We also found medicines trolleys were not always locked when not in use and medicines administration records were not always fully completed.

There were processes in place to monitor and review the safety and general maintenance of the premises. However, we found a number of safety issues with the premises and safe working practices. Upper windows did not have restrictors, to limit their opening that met with current Health and Safety Executive guidance. We found a number of products, including cleaning materials that were not locked away or supervised when being used, particularly in relation to the dementia unit. This meant there was a potential for people to be harmed.

We spent time in various parts of the service, observing care. At times, staff levels were not sufficient to meet people’s needs fully. The registered manager told us that she used her experience of working in care to assess the number of staff required and did not use any monitoring tools, meaning we could not be sure appropriate levels of staff were always available. Following our inspection, the manager told us that she was now completing a new form to enable an assessment of staffing levels which would show that they were staffing the home with suitable numbers of staff. She also said she had been given confirmation that more staff could be employed on the dementia unit in particular.

People said they felt safe living at the home and said the staff treated them well. Staff had received training regarding safeguarding and the protection of vulnerable adults. They said they would report any concerns to the registered manager.

Staff told us they felt supported and well trained and we confirmed that staff supervision had taken place regularly and training was up to date. We noted, however, that staff had only started to receive an appraisal in this current year having not received one previously with the provider. Not all appraisals were completed.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’. It also ensures unlawful restrictions are not placed on people in care homes and hospitals. We found the provider was complying with its legal responsibilities, but records were not always in place to confirm this.

People were able to enjoy enough food and refreshments to meet their needs and if people needed additional support from staff, this was provided. Special dietary needs were also catered for. People were supported to access a range of health care professionals. Examples included appointments with their GP and visits to hospital for any emergencies arising and also scheduled appointments with specialist practitioners.

People were clean and appeared comfortable. Staff spoke compassionately with people and treated them with respect, and also promoted choice and independence. When a person was distressed staff supported them skilfully with warmth and kindness.

A range of audits and checks were completed at the service. The provider also completed quality monitoring checks and health and safety audits. We found, however, that the issues we had found during our inspection, had not always been found during these audits or had been found and appropriate action not taken. For example with regard to addressing the issues with the management of medicines and fitting window restrictors.

We have made two recommendations in connection with respecting people's belongings and DoLs authorisations.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the safe care and treatment, staffing and good governance. You can see what action we told the provider to take at the back of the full version of the report.

Overall, we found people were happy living at the home and felt well cared for. Comments from people who used the service included; 'The staff are fantastic.I really can't complain' and 'The care is good. The staff look after me and give me my medication. If I use my call bell the staff always respond' and 'It's not home but it's the next best thing. We are looked after and treated well by all of the staff' and 'Absolutely great. I love it. I can do bits and pieces of things myself but if you are struggling with anything all I have to do is ask'.

We looked at the measures in place to safeguard people from abuse and we found there were appropriate systems to enable this. Each person we spoke with told us they felt safe and secure living at the home. Relatives told us they were aware of the safeguarding procedures.

We looked at staff personnel files to ensure staff had been recruited appropriately and safely. Each file we looked at contained two references from previous employers and a CRB reference number.

We found there were effective systems in place to monitor the quality of service provision. This was done with the use of audits, surveys and the monitoring of accidents and incidents.

We looked at the care records and found that assessments and care plans were in place. We saw that they were regularly reviewed to make sure that people's needs were met.

We toured the communal areas and some of the bedrooms and found that all areas were comfortable and well furbished. We also found that there was no malodour throughout the building.

We also looked at staff support and training. We saw that staff records and found the staff were well trained and there were good systems in place to ensure they were well supported in their work.

We found that people had good information and support to make decisions about their care or air their views about the home. We also found that good systems were in place to support people living at the home and the staff to raise concerns or complaints.