Shannon Court

Updated 14 May 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 carried out by two inspectors and an Expert by Experience.

An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Shannon Court 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. Shannon Court is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

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.

What we did before the inspection

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 reviewed all the information we held about the service and obtained feedback from the local authority and health care professionals.

We used all this information to plan our inspection.

During the inspection

During the inspection we spoke with 13 people and one relative. We also spoke with 12 staff, which included the registered manager and deputy manager. We reviewed the care plans of 10 people. We looked at the recruitment files for five staff, medicines records and other records, policies and audits used by the service.

After the inspection

Following the inspection, we reviewed information sent to us by the registered provider in relation to staff training, supervision, audits, meetings and surveys. We also received feedback from three relatives.

Updated 14 May 2022

About the service

Shannon Court is a care home providing accommodation and personal care for up to 53 people, some of whom may be living with dementia. The service is divided into five separate living areas, each with their own dining room and lounge. In addition, there is a large communal lounge area on the ground floor, together with extensive grounds and smaller courtyards for people to sit in. At the time of our inspection, 40 people were living at the service.

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

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support best practice.

The service followed a recruitment process for prospective staff, although we did find a couple of documents missing for two staff members. We have issued a recommendation in relation to this to the registered provider.

We saw care being provided to people from a sufficient number of staff at the time of inspection. However, we received mixed views from people and relative about staffing levels. We discussed this with the registered manager who took immediate action to address our observations on one unit, where more staff were needed.

People received the medicines they required and they told us they felt safe living at Shannon Court and that the service was always clean. Our observations confirmed this as we saw housekeeping staff cleaning throughout the day. We also observed staff wearing their PPE in line with Government guidance.

People told us staff were kind and caring towards them and people were enabled to retain as much independence as they wished. Staff treated people with respect and took time to engage and socialise with them.

People were provided with sufficient food and drink and where they required health care professional input staff supported them to access this.

People lived in an environment that was suitable for their needs. It had adaptations and equipment appropriate for people and for those living with dementia we observed sensory areas, and sufficient space so people could walk when they wished.

People were provided with a range of activities. These were slowly increasing as the service came out of a COVID-19 outbreak. Outdoor activities and outings were being planned and these would be helped by the improvements being made to the external grounds.

Although the service was not providing care to anyone with a learning disability, we expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was able to demonstrate how they would meet the underpinning principles of Right support, right care, right culture should they provide care to an autistic person or someone with a learning disability.

Right support:

Model of care and setting maximised people’s choice, control and independence;

People were given choice and were involved in decisions around their care.

Right care:

Care was person-centred and promoted people’s dignity, privacy and human rights;

Due to the quality of people’s care plans and staff’s knowledge of people, there was evidence to suggest people would receive person-centred care.

Right culture:

Ethos, values, attitudes and behaviours of leaders and care staff ensured people using services led confident, inclusive and empowered lives;

There were systems in place to help ensure that the values and culture was such that people could automatically expect a high quality, person-centred service.

Staff felt supported and they were provided with appropriate and sufficient training to enable them to carry out their role. They had the opportunity to meet with their line manager regularly to discuss their role or any concerns, and staff meetings were held where they could talk about all aspects of the service.

There was a clear governance process in place and the registered manager had identified areas that required further work and was working to an action and continuous improvement plan. The management team worked well together and had a clear vision on how they wished the service to look in the future. They were being supported by external agencies in order to achieve this.

Complaints and concerns were listened to and responded to and where incidents and accidents occurred learning took place.

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

We last inspected this service in November 2019. The last rating for this service was Requires Improvement (report published 2 June 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 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, we identified a new breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – need for consent. We also found that recommendations we had made to the registered provider had been addressed. These related to staff training, the environment and care plan reviews.

Why we inspected

This inspection was prompted in part due to concerns received about a high number of falls occurring, a lack of robust diabetes management, insufficient staff, lack of following the principles of the Mental Capacity Act 2005 and poor practices in relation to the use of medicine patches for pain control on people.

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 found the provider had identified shortfalls and had taken action to mitigate risks to people as well as address the concerns that had been highlighted to us. However, we have found evidence that the provider needs to make improvements to their processes in relation to consent and the Mental Capacity Act 2005. Please see the key question of Effective of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the need for consent at this inspection.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.