Shoemaker Place

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The provider failed to maintain adequate oversight of medicines storage, administration, and recording, to ensure systems in place to review people’s needs and risks were effective, to ensure investigations into complaints received were effective and to ensure an effective learning culture was in place. While processes were in place to monitor people’s needs and risks, concerns were not always escalated to health partners due to lack of guidance for staff in care plans and this had not been identified in audits. The provider did not always ensure people received training relevant to their role, oversight of fire safety and infection prevention control procedures was not always effective. While the provider was working closely with the local authority and were working towards an improvement plan, improvements had not been fully embedded at the time of our inspection. Staff felt the culture in the organisation had not always been supportive under previous management however were hopeful the culture will improve under the new management. The provider recognised there needed to be an improved culture and they had started to make changes to help the staff feel more supported and involved. Information about staff could whistle blow and raise concerns was available in the reception area. The provider worked with community providers to enable people to participate in activities. The provider respected staff member’s individual cultural and religious beliefs and adjusted the staff rota to allow staff to observe these.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff felt the culture in the organisation had not always been supportive under previous management however were hopeful the culture will improve under the new management. One staff member told us, “Management have not always dealt with issues with and between staff”. Another staff member told us, “I am happy with the new manager and would feel confident raising issues which has not always been the case.”

Staff received training in equality and diversity. They understood about equality and diversity and wanted to provide compassionate care. During our inspection, staff demonstrated respect for each other and the people they were supporting. The operations manager explained they recognised there needed to be an improved culture and they had started to make changes to help the staff feel more supported and involved.

While staff mostly felt supported by each other and knew how to raise concerns with managers, they had not always felt listened to by management but were hopeful things would change with the new manager.

A new manager had started in post shortly before our inspection. The operations manager who was overseeing the service had worked closely with the local authority and had started to introduce a range of changes and improvements. However, managers had not identified or mitigated some of the risks to people's safety and the quality of care.

While staff we spoke to knew how to whistle blow and to raise concerns, they expressed they had not always been listened to by the previous management team but were hopeful things would change under the new manager. The operations manager told us they recognised this had been an issue and was working towards an improvement plan.

Information about staff could whistle blow and raise concerns was available in the reception area.

Staff told us how the provider promoted equality and diversity in the staff team and staff were able to observe cultural and religious events.

The provider respected staff member’s individual cultural and religious beliefs and adjusted the staff rota to allow staff to observe these. Staff received equality and diversity training.

The operations manager told us improvements were needed in the governance of the service and there was a plan in place for this.

The provider failed to maintain adequate oversight of medicines storage, administration, and recording. For example, medicines audits failed to identify missing information on controlled drugs, liquid medicines and creams, out of date medicines had not been discarded and some, lack of details and medicines in people’s care plans and staff not recording the reasons for giving people PRN medication. The provider failed to ensure systems in place to review people’s needs and risks were effective. For example, audits of care plans did not identify a lack of guidance for staff for people’s bowel, nutrition and behavioural needs. This meant people were not always referred to health agencies when required. The provider failed to ensure systems in place to keep people safe were effective. For example, investigations were not always carried out when incidents had been identified. When investigations were carried out, the learning was not shared with the wider team. The provider failed to ensure investigations into complaints received were effective. For example, the learning from complaints was not always shared with the wider team. The provider failed to ensure an effective learning culture was in place. The provider did not always ensure people received training relevant to their role. For example, although staff supported people with their end-of-life needs, not all staff had received end-of-life training. The provider’s oversight of fire safety procedures was not always effective. For example, fire drills lacked detail about how the drills were held or how long it took to evacuate people. The provider’s oversight of infection prevention control was not always effective. For example, cleaning records did not always include enough information about which bedrooms had been cleaned on a daily basis.

While people did not express any concerns about how the provider works with partner agencies, we found the provider did not always escalate health concerns when required.

While staff told us they work closely with health agencies and escalate health concerns when needed, care plans did not always include information about when staff should involve other agencies in meeting people’s clinical needs.

Partner agencies told us the provider had not always identified people’s risks or escalated concerns to them in a timely way.

While processes were in place to monitor people’s needs and risks, concerns were not always escalated to health partners due to lack of guidance for staff in care plans and this had not been identified in audits. This meant people were at risk of not having their health needs met. The provider worked with community providers to enable people to participate in activities. For example, there were regular visits from Stoke City Football Club to promote people’s physical wellbeing, singers and musicians and hairdressers.

The operations manager told us the provider was working closely with the local authority and were working towards an improvement plan. These included improvements to managing medicines, people’s skin needs and escalating risks. However, the improvement plan had not been fully embedded at the time of our inspection. This meant people remained at risk of unsafe care or care which did not meet their needs.

The systems and processes for improving quality had not always been effective. While the provider identified when things went wrong, these were not always investigated or the lessons learnt were not shared with the wider team. Audits of care plans did not always identify when people’s needs changed and people’s risks were not always escalated. This meant people remained at risk of unsafe care or care which did not meet their needs.