Shenstone Hall Nursing Home

⚠ The provider determined staffing levels on the number of people living in the home instead of on an assessment of people’s needs. This meant people sometimes waited longer for support when they needed the assistance of two members of staff. The staffing levels were not being continuously reviewed and adapted …

⚠ People did not always have risk assessments and risk management plans in place. For one person needing the support of two members of staff to move safely, no risk assessment had been completed since they moved in and there was no risk management plan in place, demonstrating staff may not …

⚠ Improvements were needed to the management of medicines. The amount of medicine in stock was not always added to the MAR or brought forward onto the chart in use, meaning we could not check if the medicine stock was correct. Where changes were made to the MAR charts, staff did …

⚠ Improvements were needed to people’s care records to identify all their support needs.

⚠ Call bells were not accessible to the majority of people within communal areas, which made seeking staff assistance difficult. Call bells for people’s rooms were not always answered promptly.

⚠ The manager’s quality assurance systems were not effective. Action plans in place had not identified the shortfalls found. Risks to people’s health and well-being were not being promptly assessed and risk management plans were not always in place. Medicines audits had not identified the shortfalls found with the recording of …