Shandon House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People and their relatives told us they felt safe at Shandon House. Staff demonstrated a good knowledge of safeguarding and when to recognise and report concerns. Documentation around safety required improving. For example, risk assessments were not always fully detailed or reviewed. Best interest decisions had not been fully documented and accident and incidents lacked details and action plans to aid learning and prevention of reoccurrence. The registered managers were receptive to our feedback and had already begun proactively working with other agencies to drive these improvements. Staff training was up to date and relevant. Staff told us they felt supported and enjoyed their job. The home was clean and tidy, with good maintenance management in place. Medicines were administered safely, and regular checks were undertaken to ensure processes around medicines were robust.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they felt safe, and we had some lovely feedback from relatives regarding the care provided. People and their relatives both said they would feel comfortable raising any concerns they had, and they were confident action would be taken as a result. One person told us, “I did complain once, problem was sorted by the [registered] manager”.

Staff were given some opportunity to learn and make improvements in their practices, this was not always consistent, however we did see examples of improved practice. For example, on the first day of inspection only one member of staff worked at night. This had recently been reviewed and the registered manager informed us that a second staff member of sleeping night staff would shortly be in the home at night-time in the event of any emergency evacuation being required. A practice evacuation was undertaken to assess the effectiveness of staffing, lessons learnt, and action taken forward.

Systems and processes were being improved, including auditing to ensure that lessons learned could be taken forward. We found one incident which had been reported to the local authority and police, but no incident form had been completed and the incident had not been included in the person’s daily records. Appropriate information had been shared with staff via handover. The manager was aware improvements were needed to ensure records were more robust, this included better auditing of care plans, accidents and incidents and documentation overall.

People felt involved in their care and relatives told us staff at the home kept them informed. One relative told us, “Staff seem pleasant, they got to know me as well as [person], I’m happy with their care and have had meetings to discuss any changes.”

Staff used an electronic messaging application to ensure handovers were robust. This enabled them to keep updated with any changes in people’s care, and any additional support which was needed to keep them safe.

Healthcare professionals provided positive feedback and advised that staff are responsive to supporting strong pathways to good care. For example, one professional told us, “Staff facilitate a timely response to identify and address [people’s] acute needs in regards of pain relief, constipation relief and other self-limiting minor ailments. This is beneficial to people and in turn reduces unnecessary costs and staff time to the NHS.”

Processes were in place to develop people’s care plans however these were not always robustly followed. Some care plans and risk assessments had not been reviewed regularly and missed some information, for example, details of people who used alcohol. Documentation of wounds or bruising needed to be improved to clearly record size and a description of the wound or bruise, a body map and a photograph if appropriate, with a clear plan of care recorded including pain management. This was not always in place and, whilst we saw no immediate impact to people, it could present a risk in relation to transitions and pathways of care.

People told us they felt safe, and that staff provided a safe environment for them to live in. Relative comments also supported this. One person said, “Safe, oh yes definitely, just by having people around, I have become part of a community after 20 years on my own. I need help with the stairs but can be independent walking around with my stick or walking frame. Staff are very good, pander to my every whim! No abuse ever.” A relative added, “I feel [person] is kept safe, no falls since she came in which is good, I am happy with her care.”

Staff had completed safeguarding training, and those we spoke with knew how to report a safeguarding and could easily list the types of abuse. Staff had access to the safeguarding policy. All staff told us if they had any concerns, they would raise these with either of the registered managers and were confident they would be dealt with appropriately.

People were visibly comfortable and settled in the presence of staff. We saw staff responded to people’s needs safely and appeared to know people well.

The home has a safeguarding policy in place and staff demonstrated a good understanding of this. Mandatory safeguarding training was completed, and the registered managers had oversight of this. Best interest decisions had not been recorded for all decisions, for example, where sensor mats or bed rails were being used. There were also gaps in the recording of decision specific mental capacity assessments. Accident and incident reporting and documentation needed improvement, including a clear description of what has happened and whether it was witnessed or not, follow up actions and lessons learned. We found one incident which had not been appropriately recorded in the persons daily care records or reported to CQC. The registered managers were receptive to this feedback and had started taking action to address matters.

People spoke positively about how staff supported them to remain independent and helped them manage risks. A relative told us, “I feel that [person] will be kept safe despite only being a resident for a short time, staff were all happy and helpful and I witnessed a carer walking them carefully in the lift and encouraging them with their mobility. We witnessed a good ambience around the home.”

The registered managers were aware that accident and incident processes needed to be improved to ensure risks were effectively managed. They had already taken proactive steps to engage with the local authority market support team to support improvements. Staff demonstrated a good knowledge of risks to people and how they could minimise these.

People were supported to spend their time how they wished. We saw people going out alone and with relatives, accessing the garden and spending time in communal areas or returning to their rooms. People were supported to take positive risks to encourage maintaining their independence.

Registered managers and staff had a clear understanding of people’s needs and the risk associated with this, however, this was not always supported by clear robust documentation. Care plans and risk assessments needed to be reviewed to ensure they were in place for all identified risk and care needs. Management were responsive to this feedback and were working with the local authority to facilitate improvements.

People told us they thought the home was clean and that they liked their rooms. Relatives said they had no concerns. People enjoyed the garden and chose which communal areas to sit in throughout the day.

The environment was well maintained and clean. Staff were clear on what their responsibilities were in relation to the upkeep of the home. There were cleaning schedules in place to guide staff. Maintenance was well managed and there was clear information to demonstrate services and system checks were completed.

People’s rooms were personalised with their own belongings and well maintained. Communal areas had been kept tidy and had a nice, homely feel. There was access to a large garden with chickens which we observed people enjoying.

Robust systems and processes were in place to ensure maintenance and services were up to date and well managed. However, risk assessments were not in place about staff walking through kitchen with laundry and people using the kitchen safely. People and staff used the kitchen as a point of access to and from the garden therefore there was regular through traffic. Laundry being carried through presented both an infection control and fire risk. This has now been addressed by the management and access has been discussed. All staff have been reminded regarding appropriate use of personal protective equipment (PPE). Maintenance files and logs were well organised, the maintenance person was aware of what needed doing and when, such as sending of the Legionella samples, that the new smart meter was due, and that the lift servicing was coming up.

Most people had a high level of independence so did not need a lot of staff support, those who did said they received the help they needed. One person said that they could always catch a staff member if they needed one. Other people told us, “Staff numbers have picked up recently, no different at weekends, staff come quickly if you call,” and “Staff are very nice, no problem with staff numbers, they have a good understanding of me.” Relatives were aware that if people’s needs increased, they may have to move to a service which was able to meet these needs.

Staff rotas did not always indicate leadership available each shift. This was fed back to the registered managers who took action to address this. Staff we spoke with felt they received the training they needed and felt supported. Staff said both registered managers were approachable, and they received regular and appropriate supervision.

Staff in the communal areas were not always very present, however people had a high level of independence so were able to come and go as they chose, and regular supervision was not always required. We carried out observations and saw staff interacting with people in a kind and supportive manner, chatting to people and supporting them when required.

Recruitment processes were in place; however, these were not always robust. For example, staff who had returned to work at Shandon having previously left did not all have 2 independent references and the provider had completed one themselves. We discussed this with the provider and they are now aware to gain 2 independent references. Documentation around who had completed inductions and had been signed off needed to be more robust. Systems and processes were in place to ensure staff had the correct skill set to keep people safe. Management had oversight of the training matrix and reminded staff when training was due. Mandatory training had been completed by staff which included: First aid, moving and handling, safeguarding, food hygiene, infection control, mental capacity and fire safety. Staff had the opportunity to complete further training if they wished and 2 staff were also completing their level 5 management.

People felt the home was kept clean and tidy and had no concerns. Relatives confirmed that the home is always clean and tidy when they visit. One told us, “[Person’s] room is clean and tidy with some of their own bits and pieces around."

Staff had no concerns in relation to infection prevention and control. They told us they had access to personal protective equipment (PPE). Staff had completed appropriate training and regular checks of correct use of PPE were completed. Management were receptive to our feedback about laundry being carried through the kitchen and addressed this immediately following the inspection. Please see the safe environments section for more detail of this.

We observed numerous personal protective equipment (PPE) stations around the home which were fully stocked. The home was clean and tidy. Staff and residents were seen accessing the kitchen and preparing food without aprons on. This was raised with management and addressed whilst we were on site. The home had a regular cleaner and in their absence, cleaning was completed by care staff. The laundry room was seen to be clean and tidy.

Processes were in place to ensure effective infection prevention and control. Cleaning schedules and deep clean records were in place and utilised by staff. When the regular cleaner was not available, instructions were in place to guide care staff to ensure the cleanliness of the home was kept up. Managers carried out audits to identify any areas of deep cleaning required and action was taken to address this.

People spoke of confidence in staff regarding their medicines. Relatives also raised no concerns in this area and all comments were positive. Examples included, “[Person’s] medication has been sorted and given correctly I believe”; “Medication given on time mostly, any changed would be discussed with my son;” and “Medication on time and I understand them all and can discuss them with the staff.”

Staff were proactive in reducing medications where possible to ensure people were not unnecessarily taking medicines they did not need. Some people were able to self-administer their medicines, this was documented, and staff demonstrated a good knowledge of what support people needed. Staff told us they received training and checks were carried out by the registered managers to ensure they remained safe and competent to administer medicines.

Systems and processes were in place to ensure safe management of medicines. Medicine administration records (MARs) were completed accurately. There was guidance for staff on what action to take should any errors be noticed. Staff were seen to wear tabards when administering medicines. Staff asked people if they required their as and when (PRN) medicines. Guidance was in place to support staff identify when these may be appropriate to give or offer. Audits had been undertaken in relation to medicines and we saw action had been taken to address concerns.