CQC report explained · a residential care home
What the CQC found at Sherdley Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about most infection control measures, including PPE, testing, admissions and outbreak management. They were only somewhat assured about the premises layout and asked for better social distancing through rearranged furniture and smaller gathering areas.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, April 2021
Sherdley Manor was inspected but not rated; inspectors found mostly safe infection control, with improvements needed to the layout and social distancing.
This was an unannounced, targeted inspection during the coronavirus pandemic. Inspectors looked at infection prevention and control measures, rather than carrying out a full inspection of the home.
Inspectors were assured about visitors, admissions, personal protective equipment, testing, outbreak management and the infection control policy. Staff were not working at other homes, and agency staff were only used in emergencies.
The home had improved its cleaning schedule and managed clinical waste safely. However, inspectors were only somewhat assured about the layout and hygiene arrangements. They asked the home to improve social distancing by rearranging furniture and creating smaller areas for residents to gather. The service was inspected but not rated.
Infection control checks
The home had regular testing for staff and residents, and a vaccination programme was underway.
“The home had a regular testing programme in place for staff and residents. A vaccination programme was also underway.” from the report
Use of PPE
Inspectors saw staff wearing PPE correctly. The home had areas where PPE could be put on and removed safely.
“We saw staff wearing PPE correctly and maintaining social distancing where possible.” from the report
Cleaning and waste
Cleaning schedules had been strengthened, including more frequent cleaning of surfaces that people often touched. Clinical waste was managed safely.
“Cleaning schedules at the home had been reviewed and enhanced. This included regular cleaning of frequently touched surfaces throughout the day.” from the report
Reducing cross-infection risks
Staff did not work across different homes, and agency staff were used only in emergencies. Staff breaks were limited to two people at a time.
“Staff did not work at other homes and agency staff were only used in emergencies.” from the report
Layout and social distancing
needs fixingThe limited space made social distancing more difficult. Inspectors asked the home to rearrange furniture and create smaller areas for residents to gather.
“We were somewhat assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
- 01What changes were made to the furniture and communal areas after the inspection?
- 02How do you now support social distancing when residents gather?
- 03How are PPE areas kept separate and used safely?
- 04How often are frequently touched surfaces cleaned, and how is this recorded?
- 05How are testing and vaccination arrangements currently organised for residents and staff?
This was an unannounced targeted inspection of infection prevention and control practices; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 23 April 2021 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, February 2019
Sherdley Manor rated Good; inspectors found kind, safe care, but medicines receipt records needed review.
This was an unannounced inspection over two days. The inspector spoke with people living there, relatives, staff and visiting healthcare professionals. They reviewed care records, medicines records, staff training and recruitment records, and safety checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from abuse, supported by trained staff, offered suitable food and healthcare, and treated with kindness and respect.
There had been improvements since the previous inspection, which was rated Requires Improvement. Mental capacity assessments, best-interest decisions and quality checks were better. However, the home was asked to review how medicines received into the service were recorded.
Kind and respectful care
People and relatives described staff positively. Inspectors saw that staff knew people well and supported them in a calm way.
“People were treated with kindness, dignity and respect.” from the report
Suitable staffing
Inspectors found enough suitably trained and experienced staff to meet people’s needs safely.
“Sufficient numbers suitably trained and experienced staff were on duty to safely meet people's needs.” from the report
Improved decision-making
The home had improved its mental capacity assessments and best-interest decisions since the previous inspection.
“Where people did not have capacity to make specific decisions, systems were in place to ensure they had maximum choice and were supported in the least restrictive way possible.” from the report
Better quality monitoring
The systems used to check care quality and safety had become more effective. Audits identified improvements and action was taken.
“The system for monitoring the quality and safety of the service had improved since the last inspection.” from the report
Personalised support
Staff understood people’s preferences, communication needs and care plans. People could choose whether to join activities and had opportunities to access the community.
“Staff understood and applied the principles of person-centred care and support” from the report
Medicines receipt records
needs fixingA short course of tablets was found in the medicines cabinet without a record showing that it had been delivered to the home. Inspectors found no evidence that the person was harmed, but recommended a review of the system.
“We recommend that the provider reviews the systems in place for the receipt of medicines.” from the report
Emergency plan access
needs fixingThe contingency plan for emergencies was kept in the office and could only be accessed during office hours. The manager agreed to move it so it would always be available.
“The contingency plan for use in the event of emergencies was kept in the office and was only accessible during office hours.” from the report
- 01How do you now record and check medicines when they are delivered to the home?
- 02Where is the emergency contingency plan kept, and can staff access it at all times?
- 03How will you continue the improvements made to mental capacity assessments and best-interest decisions?
- 04How are relatives involved in care plan reviews and decisions about changing medicines?
- 05How do your quality audits identify and follow up problems in care and medicines records?
This was a planned, unannounced inspection covering all five key questions, including both the care provided and the premises. This explanation was written from the published report of 26 February 2019 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 Sherdley Manor
3 rated inspections over 4 years: the service has held its Good rating throughout.
- April 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 12 March 2011.
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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