This inspection took place on the 30 October 2018 and was unannounced. This was the first comprehensive inspection of the service since it changed legal entity in October 2017. The service had been inspected under the previous legal entity and was rated overall good in January 2017.

Shirelodge Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Shirelodge Nursing Home accommodates up to 54 older people in a purpose-built building. People were accommodated on the ground and first floor of the building. The service provided support to people requiring general nursing, residential care and people living with dementia and memory loss. At the time of our inspection there were 47 people living there.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People did not always receive care that protected them from an act of control and restraint that was unnecessary and disproportionate.

People told us they felt safe, however there was a concern that incidents were not always reported to the registered manager when they were witnessed by staff.

People received their medicines when they required them, however staff who administered medicines had not had their competency assessed on a regular basis. Although staff felt supported, not all staff received regular formal supervision.

The environment required some refurbishment to ensure it was suitable to meet people’s needs and improvements were required in relation to the care planning documents being consistent across the service.

The systems and processes in place to assess, improve and monitor the safety of the service were not always effective. The provider did not have a policy in place that offered guidance on how often and in what circumstances staff should have a renewed Disclosure and Barring Service (DBS) check.

People’s needs were assessed prior to coming to the home and risks to people had been identified and measures put in place to mitigate any risk. There were sufficient staff to meet the needs of the people; staffing levels were kept under review.

People were involved in decisions about the way in which their care and support was provided. Staff understood the need to undertake specific assessments where people lacked capacity to consent to their care and / or their day to day routines. People’s health care and nutritional needs were carefully considered and relevant health care professionals were appropriately involved in people’s care.

People were cared for by staff who were respectful of their dignity and who demonstrated an understanding of each person’s needs. This was evident in the way staff spoke to people and the activities they engaged in with individuals. Relatives spoke positively about the care their relative received and felt that they could approach management and staff to discuss any issues or concerns they had.

The registered manager was approachable and people felt confident that any issues or concerns raised would be addressed and appropriate action taken.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.