Background to this inspection
Updated
11 June 2019
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. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the home, and to provide a rating for the home under the Care Act 2014.
Inspection team:
• This inspection was conducted by two inspectors.
Service and service type:
• CMG Shardeloes is a residential care home that provides personal care for to up to 9 people. At the time of the inspection seven people were residing at the home.
• The home had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the home is run and for the quality and safety of the care provided.
Notice of inspection:
• This inspection was unannounced.
What we did:
• We used information the provider sent us in the Provider Information Return. (PIR) This is information we require providers to send us at least once annually to give some key information about the home, what the service does well and improvements they plan to make. We looked at information we held about the home including notifications they had made to us about important events. We also reviewed all other information sent to us from other stakeholders for example the local authority and members of the public.
• On the day of inspection we spoke with five people living at the home, three care staff and the deputy manager.
• We reviewed four people’s care files, three people’s medicines records and a range of other documents in relation to the care people received. We reviewed two staff files and other relevant documents relating to the home.
• We reviewed records of accidents, incidents and complaints and audits and quality assurance reports.
• We also looked at environment and facilities within the home.
Due to the registered manager not being at the home on the day of inspection we requested further information not available to us on the day. This included documents relating to recruitment, training and staffing levels. These were sent promptly after the inspection.
Updated
11 June 2019
About the service:
• CMG Shardeloes 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.
• CMG Shardeloes accommodates up to nine people throughout one building and an annexe apartment, at the time of the inspection they had seven people living at the home.
People’s experience of using this service:
• Staffing levels were not always safe to ensure that people’s needs were met in a timely manner.
• Risks were assessed and recorded so that staff were clear on how to support people safely. Due to staffing levels it was not always clear whether these were being met, for example in personal evacuation escape plans.
• Quality assurance systems were not always conducted effectively in order to identify and drive improvements, predominantly in identifying low staffing levels.
• Medicines were managed in line with best practice guidance.
• The provider had documented staff training, supervision and appraisal in a clear format.
• We received views from people as to the care received, all people spoken with felt staff always displayed compassion and care.
• The provider had made efforts to make the environment and activities suited to the needs of the people living at the home. In some examples this had been completed.
• People stated that they were really happy living at the home and loved the staff that supported them.
• People’s legal rights were followed according to the Mental Capacity Act and all staff were aware of each individual’s legal rights.
Rating at last inspection:
• At our last inspection we rated the home ‘good’. (report published 16 November 2016)
Why we inspected:
• All homes rated "good" are re-inspected within two and a half years of our prior inspection.
• This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.
Follow up:
• We will continue to monitor intelligence we receive about the home until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk