Archived: Shottendane Nursing Home

Updated 7 October 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.

Service and service type

Shottendane Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement dependent on their registration with us. Shottendane Nursing Home is a care home with nursing care. 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 not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before 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. We did not ask the provider to submit a provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

During the inspection we spoke with six people that use the service, and eight relatives. We spoke with eight members of staff including the provider, the providers consultant, the manager, nurses and care workers and domestic staff. We reviewed a range of records. This included four people's care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 7 October 2022

About the service

Shottendane Nursing Home supports up to 38 people who have nursing needs, dementia and require end of life care. At the time of our inspection they were supporting 23 people. Shottendane Nursing Home is a large building with care being provided over three floors and sitting in large grounds.

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

Since our last inspection, improvements to the service had been made, however there were still some areas where further improvements were needed. Checks and audits implemented needed time to be fully embedded to assess their effectiveness, and there were areas such as feedback from relatives and people where further improvements to feedback were needed. Care plans had improved but needed further development as they were not always accurate or detailed enough. Medicines management had improved however some areas still needed improvement.

People and their relatives gave good feedback about the service. Relatives told us, “We cannot fault the care,” and “I have no problems whatsoever, my [loved one] is really happy there. Really happy.” We found that systems in place to safeguard people from the risk of abuse had improved; staff had received training and competency checks. People told us they felt safe living at the service and when staff were supporting them.

Infection prevention and control had improved at the service. Staff were observed using personal protective equipment (PPE) and contaminated laundry was being separated from non-contaminated laundry. There were now sufficient staff to meet people’s needs, and staff had been recruited safely.

Risks to people and the environment had been assessed, and there was guidance in place to inform staff how best to support people. Staff we spoke with understood people’s needs and how best to support them.

People were supported to have maximum choice and control of their lives and staff supported /did them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Relatives told us the communication had improved. One relative told us, “I think the approachability is even better now. We have been given questionnaires about our loved ones to know more about our loved ones. All around its definitely improved.” People, relatives and staff told us there has been improvements to the culture. A relative told us, “ I can tell a change in atmosphere. Us as visitors we feel more welcome and we now know what’s going on. It’s been much better.” Staff understood their roles and were involved in improving the service. Staff and the manager worked with healthcare professionals to provide joined up care.

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 inadequate (published 10 September 2022) and there were breaches of regulation. 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 however there were still areas where improvements were needed.

This service has been in Special Measures since 29 April 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced inspection of this service on 24 February 2022. 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 safe care and treatment, safeguarding service users from abuse and improper treatment, staffing and good governance.

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 comprehensive inspection on 2 May 2019 to calculate the overall rating. The overall rating for the service has changed from Inadequate to 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 Shottendane Nursing Home on our website at www.cqc.org.uk.

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.

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 governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

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