CQC report explained · a nursing home
What the CQC found at Sherrington House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and inspectors found suitable systems for managing risks, accidents, incidents, staffing, medicines and infection control. Improvements were still being made to records for topical creams and as-required medicines.
- Effective?
- Requires improvement
- This question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Inspectors found effective quality and safety checks, an open management culture and good communication. The home had identified training gaps and medicine auditing difficulties and was working on them.
What inspectors found, May 2021
Rated Good; inspectors found people were safe and well cared for, but medicines records and staff training still needed improvement.
This was a focused inspection after concerns about staffing, infection control and safeguarding. Inspectors visited on 8 April 2021, spoke with people, relatives and staff, and checked care, medicine and management records.
The inspectors found people felt safe. Staffing was judged suitable, medicines were generally managed safely, and infection control arrangements were in place. Risks, accidents and incidents were recorded and reviewed.
People and relatives spoke positively about the care and management. The home was rated Good for Safe and Well-led. The other three ratings were not inspected at this visit and were carried forward from the previous comprehensive inspection.
People felt safe
People said they felt safe and that their belongings were safe. Inspectors found safeguarding procedures were followed and there were no open safeguarding cases.
“People felt safe living at the service and told us their personal belongings were safe.” from the report
Suitable staffing
People said there were enough staff, including at night and weekends. The home had arrangements to cover staff shortages at short notice.
“People told us there was enough staff on duty to meet their needs including at night and on a weekend.” from the report
Infection control
Inspectors were assured that the home had arrangements for PPE, testing, social distancing, hygiene and managing infection outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Open culture
People said they could raise concerns. The manager was visible, and people, relatives and staff gave positive feedback about the care.
“The manager was visible and promoted an open culture within the service.” from the report
Quality monitoring
Regular audits identified issues and supported improvements. The home also worked with other professionals involved in people's care.
“Systems and processes for monitoring quality and safety were effective.” from the report
Medicine records
needs fixingRecords for topical creams were not completed consistently. Guidance for as-required medicines was not always personalised, although the home had started making improvements.
“They had identified records for topical creams were not consistently completed and protocols for 'as required' medicines were not person centred.” from the report
Training gaps
needs fixingSome staff had not completed formal safeguarding training. The management team had set timescales to address this.
“Staff had received support to understand safeguarding procedures, but some had not completed formal safeguarding training.” from the report
No registered manager
needs fixingThere was no registered manager when inspectors visited. A manager had started two months earlier and said an application would be submitted.
“The service did not have a manager registered with the Care Quality Commission.” from the report
Medicine auditing
minorThe manager had identified that the medicine system was complex and difficult to audit, which could make errors harder to spot.
“The manager was following this up with other professionals.” from the report
- 01Have all staff now completed the required safeguarding training?
- 02How are topical cream records checked for completeness?
- 03How are as-required medicine protocols made specific to each person?
- 04Has the manager submitted the application to become registered?
- 05What changes have been made to make medicine audits easier and more reliable?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 19 May 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, December 2019
Sherrington House Nursing Home was rated Good overall, but inspectors found improvements were needed in how some decisions and care records were documented.
Inspectors visited without warning on 19 and 26 November 2019. They spoke with people living at the home, relatives, staff and a health professional. They reviewed care records, medicines records, staff files and the home's management records.
The overall rating was Good. Safe, caring, responsive and well-led were rated Good. Effective was rated Requires Improvement because records did not always clearly show people's decision-making capacity or how best-interest decisions had been made.
People and relatives generally said they felt safe and praised staff for being kind. Medicines were managed safely, staffing levels were maintained, the home was clean, and people's health needs were supported. The home had improved since its previous inspection and was no longer in breach of regulations.
Safe medicines systems
The home had introduced electronic medicines records after earlier problems. Inspectors found medicines and creams were being given when they should be, with staff training and regular checks.
“Systems were organised, and people were receiving their medication and creams when they should.” from the report
Kind and respectful staff
People were treated with kindness, dignity and respect. Staff knew people's needs and histories and built positive relationships with them.
“We observed all groups of staff interacted kindly with people and there was a calm and inclusive atmosphere.” from the report
Good health support
The home worked with health and social care professionals, including regular visits from a GP and a speech and language therapist. Care plans were updated when people's needs changed.
“This meant people's needs were assessed promptly and care plans adjusted to respond to any changes.” from the report
Improved records and oversight
The home had improved its daily records and management systems since the previous inspection. Audits were used to identify and address problems.
“There were comprehensive audits of all aspects of the service. When issues were identified they were addressed promptly.” from the report
Person-centred care
Care plans included people's history, preferences and communication needs. Staff offered choices and supported people to remain as independent as possible.
“Care plans were person centred and up to date.” from the report
Mental capacity records
needs fixingRecords did not always clearly explain people's capacity to make decisions. Best-interest assessments did not always clearly show the involvement of people or their representatives.
“Where people lacked capacity to make decisions for themselves clearer information about their capacity and showing decisions had been made in their best interests needed to be recorded.” from the report
Contradictory care plan information
needs fixingOne care plan referred to a medicine that had been discontinued. The error was corrected promptly after inspectors raised it.
“Some care plans contained contradictory information.” from the report
Smoking facilities
minorThe smoking area provided little shelter or privacy and sometimes caused an unpleasant smell in the entrance area. The provider said it planned to build a more suitable shelter.
“This faced a main road and afforded minimal shelter or privacy.” from the report
Activities did not suit everyone
minorAlthough activities were available and some people received individual support, feedback was mixed. Some people said they did not enjoy the activities and felt bored.
“Feedback about activities was mixed and some people said they did not like what was available and said they were bored.” from the report
- 01How do you now record a person's mental capacity for each important decision?
- 02How do you make sure best-interest decisions include the person and their representatives?
- 03Has the planned smoking shelter been built, and how do you prevent smells entering the home?
- 04How do you find out whether activities suit each person's interests, and what do you do when someone is bored?
- 05What checks make sure care plans do not contain outdated or contradictory information?
This was an unannounced, planned inspection covering all five CQC questions, with the home and the care provided both looked at. This explanation was written from the published report of 25 December 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 Sherrington House Nursing Home
8 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- May 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Sherrington House Nursing Home →
- December 2019Goodup from Requires improvementSafe: GoodWell-led: Good
Read what inspectors found at Sherrington House Nursing Home →
- November 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2014Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 January 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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