CQC report explained · a residential care home
What the CQC found at Sherbourne Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found robust safeguarding systems, suitable risk assessments, enough staff and safe medicine procedures. Medicine cabinet temperatures were not being recorded, but this was corrected during the inspection.
- Effective?
- Good
- People's needs and choices were assessed and care was reviewed. Staff received training and worked with health and other professionals to support people's wellbeing.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff supported people to make choices, communicate their views and be as independent as possible.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. People were supported with communication, family relationships, activities and complaints.
- Well-led?
- Good
- Inspectors found approachable management, regular staff supervision and strong quality checks. Families and staff were asked for their views, and the manager acted on feedback.
What inspectors found, April 2020
Rated Good; inspectors found safe, kind and personalised care, with minor gaps in medicine temperature records and understanding of information standards.
The inspection visit was unannounced and took place on 4 March 2020. One inspector spoke with people living in the home, relatives, staff and visiting professionals. They also observed care and checked care plans, medicine records, staff files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough experienced staff, safe safeguarding and medicine systems, personalised care, regular training and good links with health professionals.
There were two minor shortfalls. Medicine cabinet temperatures were not being recorded, but the home installed thermometers and started recording temperatures during the inspection. The manager did not clearly understand the Accessible Information Standard, although people were given information in formats they could understand.
The previous inspection rating was Good, published on 12 September 2017, and all five ratings remained Good. This means inspectors found the home consistently met people's needs and was well managed at the time of this inspection.
Safeguarding and staffing
The home had safeguarding systems, clear risk assessments and enough experienced staff to meet people's needs.
“The provider had robust safeguarding systems and processes in place to ensure people were kept safe; staff understood and knew how to use these systems.” from the report
Choice and independence
People were involved in everyday decisions and encouraged to be independent, including in personal care and community activities.
“People were supported to have choice in their daily lives including the meals they ate, activities they enjoyed and when to get up and go to bed.” from the report
Personalised communication
Staff understood how people communicated, including when they did not use speech, and used this knowledge to support their choices and needs.
“The staff were able to effectively support people to express their views through individual communication systems.” from the report
Strong oversight
Management used regular checks, feedback and staff development to monitor and improve the care provided.
“Quality assurance systems were robust with spot and competency checks completed regularly.” from the report
Medicine temperature records
minorThe temperature of medicine cabinets was not being monitored and recorded when inspectors arrived. The home fixed this during the inspection by adding thermometers and a recording system.
“We found the temperature of medicine cabinets was not being monitored and recorded.” from the report
Understanding accessible information
minorThe manager and provider did not clearly understand the Accessible Information Standard. However, inspectors found that people were still given information in formats they could understand.
“While the registered manager and the provider did not have a clear understanding of AIS they were providing people with information in a format they could understand” from the report
Size of the home
minorThe home was larger than current best practice guidance for this type of service. Inspectors said the building design and its place in the residential area reduced any negative impact.
“This is larger than current best practice guidance.” from the report
- 01How are medicine cabinet temperatures recorded now, and can we see recent records?
- 02How will staff learn and use my relative's preferred communication method, especially if they cannot communicate verbally?
- 03How does the home make sure its larger size does not affect people's privacy, independence or community life?
- 04How are families involved if a person needs end of life care, and how are their wishes recorded?
- 05Which activities would be available for my relative, and how would their personal interests shape the activity plan?
This was an unannounced inspection covering all five key questions, with care, the premises, records, staff practice and people's experiences considered. This explanation was written from the published report of 16 April 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, September 2017
Rated Good; inspectors found safe, kind and personalised care, with some records needing improvement.
This was an unannounced inspection on 26 July 2017. One inspector and an Expert by Experience spoke with six residents, four relatives and five staff. They also observed care and reviewed care records, medicines, staff files and management records.
The home supported 14 people, although it had places for up to 16. Inspectors found enough suitably trained staff, safe recruitment, good support with medicines and regular access to health professionals. Staff were described as kind, respectful and knowledgeable about people's needs, choices and routines.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This was the same overall rating found at the previous inspection on 31 July 2015. Inspectors identified some record-keeping issues, but did not report any breaches of regulations.
Safe staffing
Inspectors found enough staff to meet people's needs. Recruitment checks, training and staff knowledge about safeguarding and risks were also satisfactory.
“We saw that there were sufficient staff to meet people's needs.” from the report
Kind and respectful care
Staff treated people with kindness and respect. They supported dignity, personal choices and independence in everyday life.
“People and relatives told us that staff were caring and kind.” from the report
Personalised support
Staff knew people's routines, preferences, cultural backgrounds and interests. People were supported to take part in activities and maintain important relationships.
“People received care and support that met their needs and preferences in a personalised way.” from the report
Health support
People had regular contact with health professionals and staff followed health advice. Inspectors found evidence of health monitoring, medicine reviews and hospital passports.
“People were supported to maintain good health because they had regular access to healthcare professionals and received their medicines as prescribed.” from the report
Stable leadership
The home had a registered manager and a core staff team with little turnover. Feedback from relatives, professionals and staff about leadership was positive.
“We saw that there was a core staff team with little staff turnover which provided a good continuity of care to people.” from the report
One medicine record was incomplete
needs fixingOne as-needed medicine was not available during the inspection, and the record did not explain what had happened. The manager later provided an explanation and accepted that the audit should have identified the missing update.
“During our checks we found that one PRN was not available and an explanation was not given at the time of our visit.” from the report
Residents did not always understand care plans
minorSome residents did not know about their care plan. Relatives said they had been involved, but the home should make sure people understand their care and how they are involved in planning it.
“People spoken with did not know about a care plan.” from the report
Equipment records needed more detail
needs fixingOne person's records did not clearly explain why bed rails were needed. The manager arranged an occupational therapist assessment after the inspection.
“For example, one person's records did not clearly identify why bed rails were needed.” from the report
Some people were unsure about raising concerns
minorMost people said they would be happy to raise concerns, but some said they would not. Families should check how residents are helped to speak up and how complaints are handled.
“Most people we spoke with told us that they would feel happy to raise any concerns but some people said they wouldn't.” from the report
- 01How do you check that as-needed medicines are available and that every use is recorded straight away?
- 02How are residents involved in writing and reviewing their care plans, and how do you check that they understand them?
- 03What assessment supports the use of bed rails for each person, and when are those assessments reviewed?
- 04How do you help residents who are unsure about raising concerns or making a complaint?
- 05How would you support someone who wants to move to more independent accommodation?
This was an unannounced inspection covering all five CQC questions and providing ratings for the whole service. This explanation was written from the published report of 12 September 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Sherbourne Grange
3 rated inspections over 5 years: the service has held its Good rating throughout.
- April 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 7 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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