CQC report explained · a nursing home
What the CQC found at Sherrell House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that infection prevention and control measures were being followed. They checked visitors, social distancing, admissions, protective equipment, testing, hygiene and outbreak management.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Good
- This question was not assessed in this targeted inspection.
- Well-led?
- Good
- This question was not assessed in this targeted inspection.
What inspectors found, August 2020
Inspected but not rated; inspectors were assured that infection prevention and control measures were in place.
This was an announced, targeted inspection on 11 August 2020. It looked only at infection prevention and control during the coronavirus pandemic.
Inspectors were assured that the home was managing visitors, shielding, social distancing, admissions, protective equipment, testing, hygiene and possible outbreaks. They also found that the infection control policy was up to date.
The home had guidance for socially distanced visits and used different ways to update staff. Staff said the provider had done everything possible to keep people and staff safe.
The service was inspected but not rated. This means the inspection did not give a Good, Requires Improvement or Inadequate rating, and it does not provide a full assessment of all aspects of care.
Infection control
Inspectors were assured that the home had arrangements covering infection prevention, protective equipment, testing, hygiene and outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Support for visits
The home produced guidance for socially distanced visits, including advice intended to help people living with dementia.
“The service had produced a 'How to guide' for socially distanced visiting.” from the report
Staff communication and support
The provider used different ways to share updates with staff and had risk assessments and wellbeing information for staff at higher risk.
“Detailed risk assessments were in place for staff in high risk groups.” from the report
Inspectors raised no specific concerns in this report.
- 01How are the infection prevention and control arrangements described in this report being maintained now?
- 02How do you manage visits and explain mask-wearing to people living with dementia?
- 03How do you test people using the service and staff when needed?
- 04What arrangements are in place to prevent or manage an infection outbreak?
- 05Can you show me the home's current infection prevention and control policy?
This was a targeted inspection of infection prevention and control measures only; the other areas of care were not assessed or rated. This explanation was written from the published report of 27 August 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, October 2017
Sherrell House was rated Good; inspectors found significant improvements, with safe, kind and personalised care, but noted some gaps in mental capacity records.
This was an unannounced comprehensive inspection on 4 September 2017. Inspectors spoke with people living in the home, relatives, staff and managers. They observed care and looked at care records, recruitment files, training records and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer medicines systems, better risk assessments, suitable training and kind, respectful care. People’s meals, healthcare, activities and complaints were also managed well.
The home had been rated Requires Improvement after an inspection in November 2016, when several regulations were breached. This inspection found that all those breaches had been met and that significant improvements had been made. A registered manager was not in post because the previous manager had left, although a new manager had been appointed and an interim senior manager was overseeing the home.
Improved safety
Staff understood safeguarding and risks to people’s safety were identified and managed. The home had also introduced measures that significantly reduced falls.
“The provider had introduced various falls prevention initiatives that had significantly reduced the amount of falls in the service.” from the report
Safer medicines
Medicines were administered by trained staff and records were complete. Daily reviews and monthly analysis were used to identify and reduce errors.
“Medicine administration records (MAR) were accurately and fully completed, showing when people received their medicines.” from the report
Kind and respectful care
Inspectors saw staff spending time with people, communicating compassionately and respecting privacy. Care was based on people’s likes, dislikes and life histories.
“People were cared for by staff who knew their needs well. People were treated with dignity and respect.” from the report
Personalised support and activities
Care plans were developed with people and families. Activities included music, time outdoors, one-to-one support and options for people who did not join group sessions.
“Care was delivered to people in a personalised way and information was shared with staff to ensure that they were aware of people's on going needs.” from the report
Better oversight
The provider had strengthened audits, meetings and action plans. Information about incidents, complaints and medicines was reviewed to look for patterns and improvements.
“Effective systems were in place to ensure the quality of care at the service.” from the report
One authorisation record was incomplete
needs fixingInspectors could not find evidence that one condition attached to a mental capacity authorisation had been met. The acting manager reviewed all authorisations after the inspection.
“When we looked at records we did find one authorisation where we could not find evidence that the condition of the authorisation had been met.” from the report
Management was changing
needs fixingThere was no registered manager in post at the inspection. The previous manager had left, a new manager had been appointed and an interim senior manager was running the service.
“A registered manager was not in post.” from the report
- 01Who is currently responsible for managing the home while the new manager settles into the role?
- 02How were the mental capacity authorisations reviewed after inspectors found missing evidence for one condition?
- 03How do you record who was involved in best-interest decisions for my relative?
- 04What have the recent falls and medicine-error checks shown, and how are any new risks acted on?
- 05How will my relative’s individual activity preferences be recorded and supported if they do not join group activities?
This was an unannounced comprehensive inspection covering all five key questions and checking whether improvements from the November 2016 inspection had been made. This explanation was written from the published report of 4 October 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 Sherrell House Care Home
3 rated inspections over 2 years: the service has held its Good rating throughout.
- August 2020Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- October 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Requires improvementdown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 20 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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