Shoemaker Place

During our assessment of this key question, we found concerns around managing medicines, systems to keep people safe, learning lessons when things go wrong and managing people’s risks. This resulted in a breach of legal regulation in relation to safe care and treatment.

People were not supported to receive their medicines in a safe way.

Systems in place to keep people safe were not always effective.

While the staff we spoke to expressed that they knew how to identify and raise safeguarding concerns, our assessment found procedures in place to safeguard people were not always effective.

People’s risks were not always managed safely.

The provider did not always learn lessons when things went wrong.

There were systems in place to ensure the environment was kept safe. Regular infection control audits were carried out and where problems were identified, action had been taken.

Systems in place monitor people's health conditions and improve their outcomes were not always effective.

Although staff knew people well, people's needs were assessed, and care plans were in place however some care plans lacked information about the level of support required which meant people were not always referred to health agencies when needed.

Although people told us they were able to choose the care they received, and staff respected their wishes, they were not always involved in care planning.

The provider ensured appropriate decision specific mental capacity assessments were carried out however some improvements were required in recording sufficient information about how somebody had been assessed to lack mental capacity.

Professionals supporting people living at Shoemaker Place did not always feel the care home always worked well with external health agencies.

Staff treated people with kindness and compassion.

People were treated as individuals.

People were in control of the support they received as much as possible.

Staff responded to people’s needs in a timely way.

While there were systems in place to support staff including 1-1 and team meetings, these were not always effective as learning from when things went wrong had not always been shared with the staff team.

While the provider had systems in place to monitor and review people’s care needs, this did not always lead to positives outcomes.

While the provider acknowledged and responded to complaints, the learning from investigating complaints was not always shared with people and their relatives or the wider team.

While the staff we spoke with had a good knowledge of people with end-of-life needs, not all staff had received end of life training where required.

However, staff made sure people were happy and comfortable with the care they received and listened to people’s thoughts and views.

Staff provided people with information in a way which meets people’s communication needs.

People told us they were treated equally and could access support when needed.

Where people required reasonable adjustments, these were made.

The provider failed to maintain adequate oversight of medicines storage, administration, and recording, to ensure systems in place to review people’s needs and risks were effective, to ensure investigations into complaints received were effective and to ensure an effective learning culture was in place.

While processes were in place to monitor people’s needs and risks, concerns were not always escalated to health partners due to lack of guidance for staff in care plans and this had not been identified in audits.

The provider did not always ensure people received training relevant to their role, oversight of fire safety and infection prevention control procedures was not always effective.

While the provider was working closely with the local authority and were working towards an improvement plan, improvements had not been fully embedded at the time of our inspection.

Staff felt the culture in the organisation had not always been supportive under previous management however were hopeful the culture will improve under the new management.

The provider recognised there needed to be an improved culture and they had started to make changes to help the staff feel more supported and involved.

Information about staff could whistle blow and raise concerns was available in the reception area.

The provider worked with community providers to enable people to participate in activities.

The provider respected staff member’s individual cultural and religious beliefs and adjusted the staff rota to allow staff to observe these.