13 December 2021
During an inspection looking at part of the service
People’s experience of using this service and what we found
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. However, further work was needed to record Mental Capacity Assessments (MCA) and best interests’ decisions to ensure they follow good practice guidance.
Risks were managed, and people’s care plans detailed current risks and individual needs. Medicines were managed safely, and infection control measures were followed. During the COVID-19 pandemic safe visiting processes were followed to support people to maintain relationships with friends and relatives.
Staff were recruited safely and there were enough trained staff to meet people’s needs safely.
People and their relatives were involved in the planning and reviewing of their care. People were supported to maintain a balanced diet. People and their relatives were involved in planning their care. Care plans detailed people’s individual needs and preferences.
The quality monitoring processes and actions following incidents had improved. The registered manager and provider were proactive in implementing changes in order to improve the quality of care provided.
People using the service, relatives and staff commented the registered manager was approachable and making a positive difference to the quality of 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 requires improvement (report published 22 May 2021) and there were breaches of regulations 12 (Safe Care and Treatment) and 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities).
Following the last inspection, the provider was required to submit monthly action plans to show what they were doing to improve the service.
At this inspection we found enough improvement had been made and the provider was no longer in breach of the regulations.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection. The inspection was also prompted in part, due to risks identified for further follow up during our direct monitoring of the service. A decision was made for us to inspect and examine those risks.
We found no evidence during this inspection that people were at risk of harm from the areas identified.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Shirelodge Nursing Home on our website at www.cqc.org.uk
Follow up
We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.