17 July 2023
During an inspection looking at part of the service
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.