CQC report explained · a nursing home
What the CQC found at Sherwood Grange Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that personal and environmental risks were assessed and managed. Medicines, staffing, recruitment and infection control were also found to be safe.
- Effective?
- Good
- People's needs and choices were assessed, and staff supported nutrition, hydration and healthcare needs. Inspectors found that the home was following the legal principles for decisions made on behalf of people who could not make them independently.
- Caring?
- Good
- This question was not inspected during this focused inspection.
- Responsive?
- Good
- Care plans covered people's needs and were regularly reviewed. A fuller activities programme had been introduced, and staff supported communication and responded to concerns.
- Well-led?
- Good
- Inspectors found regular audits, incident reviews and management reports. Staff and relatives were positive about the management and felt listened to.
What inspectors found, May 2023
Sherwood Grange Care Centre is rated Good; inspectors found safer, more personalised care after earlier shortcomings, with no current breaches.
This was an unannounced focused inspection. Inspectors visited on 2 and 10 May 2023, spoke with people, relatives, staff and health professionals, and checked care records, medicines, recruitment files and quality checks.
The home was rated Good for Safe, Effective, Responsive and Well-led. Inspectors found that risks were managed, medicines were handled safely, staff were suitably recruited and trained, and people's health, food and drink needs were supported.
Care plans covered people's needs and activities had improved. The home had also improved its management systems and refurbishment work was continuing.
The last inspection was rated Requires Improvement in July 2022. The provider had been in breach of several regulations then, but inspectors found enough improvement and no longer found those breaches.
Safer risk management
The home had improved how it identified, monitored and managed risks linked to people's health and the environment.
“Risks were now assessed, monitored, and managed well.” from the report
Medicines
Inspectors found that medicines were stored, given and disposed of safely. Records and medicine storage temperatures were being completed properly.
“Medicines were now stored, managed, administered and disposed of safely.” from the report
Personalised care
Care plans covered people's needs and preferences, and records showed that care was being delivered in a personalised way.
“People now had plans of care in place that covered all areas of people's needs.” from the report
Activities and relationships
The home had introduced more activities, including exercise, music, films and one-to-one sessions. Events included families and the local community.
“An activity coordinator had been recruited and a fuller activity program had now been introduced.” from the report
Management checks
The management team used audits, incident reviews and regular reports to identify improvements and share learning with staff.
“Quality monitoring and assurance processes were in place.” from the report
Resident meetings had not yet taken place
minorThere had been no resident meetings by the time of the inspection. One had been arranged, so families may want to check how residents' views will be gathered regularly.
“At the time of the inspection there had been no resident meetings.” from the report
- 01How will you make sure my relative's risks and care plan are reviewed when their needs change?
- 02How do you check that medicines prescribed for specific times or for use when needed are given correctly?
- 03What activities would suit my relative's interests, communication needs and abilities?
- 04How will residents' views be gathered now that a resident meeting has been arranged?
- 05What refurbishment or redecoration work is still planned for the home?
This was a focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected during this visit, and the overall rating used the previous inspection rating for any key question not inspected. This explanation was written from the published report of 26 May 2023 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, July 2022
Rated Requires Improvement; inspectors found kind care, but concerns about safety, staffing, care planning and management.
This was the first inspection since the home registered under its current provider. Two inspectors visited unannounced on 21 April 2022 and reviewed further information up to 06 May 2022. They spoke with people, relatives, staff and healthcare professionals, and checked care plans, medicines, recruitment records and management documents.
The home was caring, and people were treated kindly and supported to make everyday choices. Staff knew people well, supported access to healthcare and helped people keep important relationships. Relatives and people reported few concerns or complaints.
However, inspectors found weaknesses in managing risks, medicines records, staffing levels, care plans and legal paperwork for people who could not make some decisions themselves. Some activities and records were not personalised or kept up to date. The home’s checks did not reliably identify these problems.
The overall rating of Requires Improvement means the home was not consistently providing safe, effective, responsive or well-led care. Four legal regulations were breached. CQC requested an action plan and said it would monitor progress with the provider and local authority.
Kind and respectful care
People and relatives described staff positively. Inspectors observed kind interactions, privacy and support for everyday choices.
“We observed kind interactions between staff and people.” from the report
Safeguarding awareness
Staff knew how to recognise and report abuse. The manager understood safeguarding responsibilities, and action had been taken after concerns were raised.
“People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse.” from the report
Staff training
New staff described a thorough induction, and staff said they received enough training to do their jobs.
“New members of staff described a thorough induction process including training relevant to their role and how to use equipment safely.” from the report
Healthcare support
People were supported to access relevant healthcare services, and referrals were made to improve wellbeing.
“People were supported to access healthcare services relevant to their needs.” from the report
Communication with relatives
Relatives said they were kept informed about events affecting their loved ones, including falls or other concerns.
“Relatives told us they were kept informed.” from the report
Risks were not always managed
seriousSome risk assessments and care plans lacked clear instructions. Fire evacuation plans were also not all kept in the fire box, increasing the risk in an emergency.
“The provider failed to ensure they safely and effectively monitored and managed risks.” from the report
Staffing pressures
needs fixingThere were vacancies, particularly for nursing staff. Staff said they could be short-staffed at busy times, which meant care was sometimes organised around tasks rather than people’s individual needs.
“In order to meet people's needs safely the home was functioning in a task orientated way rather than people led.” from the report
Medicines records
needs fixingSome medicine administration signatures and stock counts were missing. Storage temperatures were not always recorded, and there was no guidance for some medicines taken when needed.
“Medicine administration records (MARs), which detail when someone has taken their medicines and therefore can be used to assist with managing stock levels, were not being completed accurately.” from the report
Consent paperwork
seriousNot everyone had the required Mental Capacity Act assessments or best-interest decisions recorded. This meant some care was provided without the required legal framework.
“The provider failed to ensure they were working within the principles of the MCA.” from the report
Personalised care and activities
needs fixingSome care plans lacked detail or had not been reviewed for years. Staff and a relative also said there were not enough activities, particularly for people living with dementia.
“A lack of activities posed a risk people's social needs may not be met.” from the report
Weak quality checks
seriousAudits did not identify several problems found by inspectors. Inconsistent records also meant that opportunities to learn from incidents could be missed.
“We found audits that were being completed were not picking up concerns we had found, such as issues with medicines, MCA, risk management and care plans.” from the report
- 01What has been changed so risk assessments give staff clear instructions about checks, catheter care and fire evacuation plans?
- 02How are you ensuring there are enough staff, especially nurses and staff during mealtimes?
- 03Are medicines records now complete, including signatures, stock counts, storage temperatures and guidance for as-needed medicines?
- 04Have all Mental Capacity Act assessments and best-interest decisions been completed and reviewed?
- 05How are care plans being reviewed and how often are meaningful activities provided for people living with dementia?
This was an unannounced inspection covering all five key questions, with an on-site visit on 21 April 2022 and further inspection activity until 06 May 2022. This explanation was written from the published report of 26 July 2022 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 Sherwood Grange Care Centre
7 rated inspections over 8 years: the service has held its Good rating throughout.
- May 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2022Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- April 2021Inspected but not ratedSafe: Inspected but not rated
- September 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2020
Registered with the Care Quality Commission on 19 October 2020.
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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