CQC report explained · a residential care home, run by Consensus Support Services

Shrewsbury

24 Main Road, Dorrington, Shrewsbury, SY5 7JW

Requires improvementpublished 4 July 2023, 3 years ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The five questions inspectors ask

Safe?: Requires improvement; Inspectors found environmental hazards, medicines that were not always stored safely, incomplete incident records and risk assessments that were not always reviewed on time.
Effective?: Good; The report does not give a rating for Effective. It says staff had relevant training, but some additional training was needed and some capacity assessments used wording that suggested the outcome was already decided.
Caring?: Good; The report does not give a rating for Caring. Inspectors found staff were dedicated to people's needs and observed people being involved in day-to-day decisions.
Responsive?: Good; The report does not give a rating for Responsive. Inspectors found people had activities, but relatives said there were not enough opportunities in the home or community and communication support was not always available.
Well-led?: Requires improvement; Governance systems and audits did not always identify problems. Staff reported inconsistent leadership and several management changes, while records were not always complete or person-centred.

The latest report, explained

What inspectors found, July 2023

Rated Requires Improvement; inspectors found risks with the environment, medicines and management systems.

This was an unannounced inspection on 26 and 27 April and 15 May 2023. Inspectors reviewed four care plans, three people's medicine records and three staff files. They spoke with people, relatives, staff and professionals.

The home was not always safe. Inspectors found hazards such as a split fire door, a broken radiator cover, unsafe storage of cleaning products and areas that were not secure. Medicines were not always stored correctly, some creams were out of date and medicine records did not always match.

The home was also not always well-led. Checks and audits did not always find problems, records were incomplete and there was no registered manager at the time. Staff described several management changes and said stronger leadership was needed.

The overall rating changed from Good at the previous inspection to Requires Improvement. The home must improve, and the CQC will ask for an action plan and monitor progress.

What inspectors praised

Safer recruitment
Staff were recruited using checks of qualifications, character, background and criminal records.
“People were supported by staff who were safely recruited and had received training relevant to their role.” from the report
Protection from abuse
Relatives said they felt their family members were safe. Staff had training in recognising and reporting abuse and said they would speak up.
“People were protected from the risk of abuse. People's relatives all told us they felt their relative was safe.” from the report
Support during a crisis
During a crisis situation, staff showed dedication to keeping everyone safe. A detailed assessment and strategies were in place.
“At the time of our initial visit the home was supporting someone through a crisis situation and all staff showed a dedication to keeping everyone safe.” from the report
Involvement in decisions
Inspectors saw people being involved in everyday choices about what they wanted to do.
“Staff had received training in MCA, and we observed people being involved in day to day decisions about what they wanted to do.” from the report

What inspectors were concerned about

Environmental hazards
serious
Inspectors found several risks that could cause harm, including a damaged fire door, unsafe storage and unsecured areas.
“We found a number of issues within the environment which had the potential to cause harm.” from the report
Medicines not always managed safely
serious
One medicine was not kept in a lockable fridge, some creams were out of date and thickener was not secure. Medicine counts did not always match.
“People's medicines were not always managed in line with requirements.” from the report
Weak checks and records
serious
Audits did not always identify problems, and records were incomplete or stored in the wrong place. This led to a breach of the governance regulation.
“The governance processes in place were not adequately identifying risk or concern within the service.” from the report
Limited activities
needs fixing
Relatives said there were not enough activities in the home or community. Inspectors found limited evidence of meaningful activity in daily records.
“People did not always have the opportunity to achieve their desired outcomes.” from the report
Inconsistent leadership
needs fixing
There was no registered manager at the inspection. Staff described several management changes and said stronger leadership was needed.
“The leadership in the service had been inconsistent and we were advised this had, had an impact on the overall progress of the service.” from the report

Questions to ask them, based on this report

01What has been done to fix the fire door, radiator cover, cleaning product storage and other environmental hazards?
02How are medicines now stored, including refrigerated medicines, creams and thickener, and how are medicine counts checked?
03Who is currently responsible for the home, and when will a registered manager be in post?
04What changes have been made to provide more activities in the home and community?
05How are communication needs recorded and supported, including sign language or picture references?

The inspection covered the premises and care provided, but the report gives ratings only for Safe and Well-led; ratings for Effective, Caring and Responsive are not given. This explanation was written from the published report of 4 July 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Shrewsbury

4 rated inspections over 8 years: the service has held its Requires improvement rating throughout.

July 2023Requires improvementcurrent ratingdown from Good
Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Shrewsbury →
November 2019Goodstayed Good
Safe: GoodWell-led: Requires improvement
We are reading this report · the original is on cqc.org.uk
November 2016Goodup from Requires improvement
Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read this report on cqc.org.uk
October 2015Requires improvement
Safe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read this report on cqc.org.uk
March 2014
Report published without a new overall rating.
Read this report on cqc.org.uk
May 2012
Report published without a new overall rating.
Read this report on cqc.org.uk
January 2011
Registered with the Care Quality Commission on 21 January 2011.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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Shrewsbury, SY5 · 7.3 km

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What inspectors found, July 2023

Safer recruitment

Protection from abuse

Support during a crisis

Involvement in decisions

Environmental hazards

Medicines not always managed safely

Weak checks and records

Limited activities

Inconsistent leadership

Every inspection of Shrewsbury

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