Shandon House

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• 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

Improvement was required in relation to the governance and managerial oversight at the home. Quality assurance processes were not always robust enough to identify and address gaps in documentation. Accident and incidents were not routinely analysed, and this meant learning was not always provided to staff following events. We identified one significant event which had not been reported to CQC. Staff spoke positively about the registered managers and felt supported in their roles. There was an open culture at the service where people, relatives and staff all reported feeling confident to approach management should they have any concerns. The registered managers had begun to work on driving improvements within the service, working alongside external agencies, and these changes needed time to embed and be fully effective.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a warm and friendly atmosphere at the service and staff told us that they enjoyed working at Shandon House. We received some very positive feedback from people and relatives regarding the registered managers of the service. People told us they found management and staff approachable and helpful. Staff spoke of an open-door policy at the service and that managers were contactable as needed; however, it was not always clear which managers were on duty when. Due to a lack of analysis of accident and incidents, learning and improvement opportunities were at risk of being missed.

Documentation had not always been well maintained to ensure it reflected people’s needs. Staff knew people well however, there were some outdated care plans which required review. This had not been fully identified by the registered managers at the time of the assessment however action was taken to address this. The registered managers were receptive to feedback and had engaged with the local authority to improve matters at the home.

Staff spoke positively about the registered managers and told us they felt supported in their roles. The registered managers told us they worked well together to ensure people got the best care possible. Some staff were undertaking their level 5 management course to provide more managerial cover and oversight in the future. Whilst staff and leaders were aware of their roles and responsibilities, and were open and transparent during the assessment, some knowledge of what needed reporting to us at CQC was lacking. We did find one significant incident that had not been reported to us. This was immediately rectified.

Processes were in place to ensure relevant managerial cover; however, this was not always immediately obvious via the rotas. For example, when inspectors arrived on the first day of the onsite inspection there was no registered manager on site, staff told us the manager was on annual leave, it was not known who the shift leader was. It needed to be clearer who was in charge on which days, and what management cover available so staff knew who to contact when needed. This was actioned by the management team during the assessment.

Staff received regular supervision. Staff felt the management was approachable and they felt confident to be able to speak with them or raise any issues. Staff meetings took place with one scheduled following the assessment visit, to discuss areas where changes or improvements were needed.

Policies and procedures were generally in place to support staff, however some additions were needed to make these more robust. There was not a clear alcohol use policy in place at the time of the assessment visit, nor was there a nepotism policy. This is to guide staff who work together who are related to ensure that any concerns can still be raised and dealt with appropriately. These were due to be implemented following the assessment visit.

No concerns were raised by staff in relation to equality, diversity and inclusion. Staff told us they felt supported and happy working at Shandon House and teamwork was high on the agenda. The home worked closely with people to ensure any adaptations were made to enable them to continue to work safely.

Processes were in place to ensure strong workforce equality, diversity and inclusion. The provider had a relevant and up to date policy which staff were aware of. Staff had previously undertaken training in this area. This was due for renewal, but the registered managers were aware of this and arranging it for staff.

Governance and oversight by the registered managers needed to improve and was not robust across all areas. For example, people’s care plans had not been reviewed regularly and although staff knew people well and people were safe, there were gaps in their documents which required attention. Previously care plans had been overseen by a person who had left the service, and this had not been allocated elsewhere. The registered managers acknowledged this, and a plan was in place to review and update to make them person-centred and ensure they encompassed all of people’s care.

Management oversight needed to be improved to ensure robust governance systems in place including audits and reviews being completed regularly to continually monitor and improve the service. Some audits had not been completed accurately or in as much detail as required. This included care plan audits and overview of accidents and incidents. Therefore, opportunities to improve quality were missed. Policies and procedures were not always robust, for example, there was no clear alcohol policy or risk assessment in relation to people who used alcohol in the home. Some of the improvements needed had already been identified by the registered managers and they were working proactively to affect these. Plans were in place to move over to an electronic care system however the managers were not going to facilitate this until all staff felt confident on the system and the written care documentation had been reviewed and updated.

People felt that they had access to other health professionals when needed. People told us they also had access to a chiropodist and a hairdresser who visited, as well as visiting entertainers and other activities. People also maintained good links with community groups with some people attending day centres and groups to continue with hobbies.

Management told us they worked closely with and collaboratively with health professionals, for example, people were able to be seen by the paramedic practitioner during their regular visits and staff liaised with other health professionals including mental health teams, district nurses and GPs to ensure good care.

Feedback was received from health professionals. They felt that general communication was good, and people’s needs were met. One told us the home worked closely to improve people’s health and to help reduce unnecessary medicines. Relatives told us they had attended hospital appointments with relatives and the home ensured people were ready and had all required documentation with them.

Staff knew people well and the care provided was generally safe. However, the documentation of all aspects of care needed to be improved to minimise risks to people and ensure good governance.

Due to some lacking analysis of accident and incidents, staff were not always provided with the opportunity to learn and improve following certain events. The registered managers were aware that they needed to make improvements to ensure learning opportunities were not missed and that trends, themes or areas of improvement could be highlighted to staff. There were no current ongoing complaints from people living at the service and any minor issues had been addressed to prevent problems continuing.

Processes were not fully robust to ensure that learning and improvement could be made following accidents and incidents. The registered managers had plans in place to improve auditing and overall governance. The registered managers were working with the local authority to implement these changes.