Shirelodge Nursing Home

Updated 25 January 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 Care Act 2014.

This was a focused inspection to check whether the provider had met the requirements of the Imposed Conditions in relation to Regulation 12 (Safe care and treatment) and Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities). On specific concerns we had about the management of falls, accident and incidents and the systems and processes to monitor the effectiveness of the quality of the service.

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 one inspector a specialist nurse advisor 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

Shirelodge Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

This inspection was unannounced.

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 healthcare professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

We sought feedback from Northampton Healthwatch, which is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

During the inspection

We spoke with five people who used the service and five relatives to hear their experiences of the care provided. We spoke with seven members of staff including the registered manager, registered nursing staff, care staff and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records both on site and via electronic file sharing. This included three people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision and training. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 25 January 2022

Shirelodge Nursing Home is a care home providing personal and nursing care. The service can support up to 54 older adults, including care for people with dementia, mental health and physical disabilities. At the time of the inspection the service was providing care for 33 people.

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.