Shamrock House

Updated 30 June 2022

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. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was completed by one inspector.

Service and service type

Shamrock House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced on the first day and announced on the second day.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with four people who used the service about their experience of the care provided. We spoke with four members of staff including the registered manager, and a visiting professional. We reviewed a range of records. This included two complete care records, two staff files and records relating to the management of the service. We observed the medicines administration and management process including associated record keeping.

Following the inspection

We reviewed completed staff training, staff supervisions and appraisals and documentation related to window safety.

Updated 30 June 2022

Shamrock House is a residential care home providing accommodation and personal care to up to 17 people predominately living with mental health conditions, in one adapted building. At the time of this inspection, there were 16 people living at the service.

People’s experience of using this service and what we found

A range of audits and checks were completed to maintain and where required, implement any required improvements. Further work was needed to embed these systems to monitor the quality and safety of the service, for example, single pane windows had not been identified in current audits. The registered manager took immediate action to address this during inspection. We have made a recommendation about the management of window safety.

People told us they felt safe. Staff had received training in safeguarding and felt confident in reporting any concerns. Risks to people's health, safety and wellbeing had been assessed and staff understood how to help keep people safe.

Staff responded promptly and were attentive to people’s needs. Staffing levels had been increased following our last inspection. Processes in place ensured staff recruitment was appropriate with a range of preemployment checks completed.

Risks to people had been assessed and recorded. Action had been taken to mitigate risks wherever possible.

Medicines were managed and administered safely, with regular checks completed. We were assured by the measures taken to help ensure the prevention and control of infection.

People and staff spoke positively about the management of the service and their openness to feedback. The registered manager was approachable, maintained regular communication and listened to the views of others.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 13 February 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, but remained in breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We carried out an unannounced focused inspection of this service on 13 February 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve their risk management and governance systems used to monitor the quality and safety of the service.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. 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 Shamrock House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.