Shenstone Hall Nursing Home

Social Care Org · West Midlands

Overall Rating
Requires Improvement Last inspected 15 December 2015
Domain Ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Good
Well-led
Requires Improvement

View Full CQC Report

6 must-do actions

Must-Do Actions (6)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The provider must ensure staffing levels are continuously reviewed and adapted based on people’s assessed needs to ensure they are sufficient to meet people’s needs at all times.
Regulation 18 (Staffing)
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 …
Must Do
Safe
The provider must ensure that risk assessments and risk management plans are completed promptly for all people and kept up-to-date to ensure staff have the information needed to support people safely.
Regulation 12 (Safe care and treatment)
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 …
Must Do
Safe
The provider must ensure that medicines are managed effectively, including accurate recording of stock and proper countersigning of changes to Medicines Administration Records (MAR).
Regulation 12 (Safe care and treatment)
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 …
Must Do
Safe
The provider must ensure improvements are made to people’s care records to identify all their support needs.
Regulation 12 (Safe care and treatment)
Improvements were needed to people’s care records to identify all their support needs.
Must Do
Safe
The provider must ensure call bells are accessible to the majority of people within communal areas and that call bells for people’s rooms are always answered promptly to facilitate seeking staff assistance.
Regulation 12 (Safe care and treatment)
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.
Must Do
Well-led
The provider must ensure that systems to assess and monitor the quality and safety of the service are effective in identifying shortfalls, including those related to people’s health and well-being, risk assessments, risk management plans, and medicines management, and driving continuous improvement.
Regulation 17 (Good governance)
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 …
Location Details
CQC ID: 1-1121485401
Local Authority: Staffordshire
Region: West Midlands
Inspection Report
Type: Inspection report
Date: 15 December 2015
Rating: Requires improvement
Actions: 6 must-do
AI-extracted 17 Feb 2026