Shenstone Court Care Home

During our assessment, we identified concerns regarding medicines management and governance oversight. We found examples of delays in obtaining prescribed medicines, medicines recording and storage issues, stock control discrepancies and inconsistencies within some medicines-related records. Although the provider had systems in place to monitor quality and safety, these had not always identified or prevented the concerns found during our assessment. Some feedback also highlighted occasional delays in responding to people at busy times and inconsistencies relating to hydration oversight and mealtime support.

However, we found many positive aspects of care and support. People, relatives and professionals told us staff knew people well, recognised changes in their health and generally responded appropriately to their needs. Staff interactions were consistently caring, respectful and person-centred, and people were supported to maintain their interests, relationships and independence.

People were supported by staff who understood their preferences and routines, and care records demonstrated individualised approaches to managing risks, decision-making and healthcare needs. The home worked closely with a range of health and social care professionals, and feedback confirmed staff generally recognised deterioration, made appropriate referrals and communicated concerns in a timely way. We observed a welcoming environment where people were engaged in meaningful activities and supported to access community opportunities and healthcare services.

Leaders were visible, approachable and responsive throughout the assessment. The registered manager had taken some action to investigate concerns, strengthen medicines oversight and introduce additional monitoring processes. Staff spoke positively about leadership and felt able to raise concerns. Overall, we found a caring and supportive culture where people’s wellbeing was promoted, but further improvements were needed to ensure medicines management and governance systems consistently identified, mitigated and responded to risks.

We found 2 breaches of regulation in relation to the ways people’s medicines were managed safely and governance at the service. We have asked the provider for an action plan in response to the concerns found at this assessment.