Shepley House

Updated 16 August 2023

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

This inspection was completed by an inspector 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

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

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A manager was in post but had not yet begun the process of registering with CQC.

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. This included any information of concern and notifications the service is required to submit regarding any significant events happening at the service. We sought feedback from the local authority, professionals who work with the service and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used the information the provider sent us in the 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

We reviewed staffing levels and walked around the building to ensure it was clean and a safe place for people to live. We observed how staff supported people and provided care.

We spoke with 2 people who use the service, 10 relatives and 12 members of staff, including the manager, senior care workers, care workers, auxiliary 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 including 5 people's care records. We looked at 4 staff files in relation to recruitment, training and support. We reviewed several people’s medicine administration records and looked at medicines related documentation and management arrangements. A variety of records relating to the management of the service, including policies and procedures were examined.

Updated 16 August 2023

Shepley House is a residential care home providing personal care to up to 43 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 38 people using the service.

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

Systems to ensure people were safe were not always being used effectively and people’s needs, and risks were not always readily identifiable in care records. Staff were not always recruited in line with safe recruitment policies and feedback about staff and their visibility within the home was mixed. We have made a recommendation about this. Medicines were not always managed in line with good practice in relation to storage and medicines people were being given covertly, hidden in food or drink. We have made a recommendation about this. Details about how to manage risk was not always clear and records did not demonstrate that people’s assessed needs were being met. We have made a recommendation about this.

Records of accidents and incidents were not always identified in the systems for oversight but, when identified appropriate action was being taken. The service was clean and tidy, and people were encouraged to receive visits from friends and family. People felt safe and relatives generally spoke highly about staff.

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

There was no registered manager in post, and we found the service had not submitted a notification of a serious injury to CQC in a timely way. Systems for oversight were not always used effectively as areas for improvement we identify such as medicines, and accidents had not been identified. Families and staff spoke highly of the new manager and felt confident to raise concerns with them. Staff and families felt improvements were being made within 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 good (published 31 October 2018).

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.

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 changed from good to requires improvement based on the findings of this inspection.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Shepley House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to the recruitment of staff and the systems for oversight in place to ensure the service was safe.

We have made recommendations about the systems in place for the monitoring and management of risk staffing deployment and training and management of medicines administration.

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

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.