CQC report explained · a nursing home
What the CQC found at Sherwood Lodge Independent Healthcare
Not yet rated: the CQC has not published a rated inspection for this home, which is usual for a new registration.
What inspectors found, July 2023
Rated Requires Improvement; care was kind, but restrictions, staffing, activities and governance still needed improvement.
This was an unannounced comprehensive inspection on 27 April 2023. Inspectors looked around the home, spoke with staff, residents and relatives, reviewed six care records, observed residents and examined policies and other documents.
The overall rating improved from Inadequate at the previous inspection in May 2022. Special measures were lifted. Inspectors found better risk assessments, care records, safeguarding work, incident reporting and the environment. Caring was rated Good.
The home still needed improvement in all other areas. Inspectors found blanket restrictions that were not clearly justified, incomplete staff training and supervision, limited meaningful activities, some unfinished building work, insecure records and weak quality checks.
Improved risk management
Staff completed individual risk assessments and knew how to respond to residents' known risks. Care records were up to date and accessible.
“Staff completed risk assessments for each resident on arrival, and reviewed this regularly, including after any incident.” from the report
Safeguarding
Staff had safeguarding training, knew how to report concerns and worked with other agencies to protect residents.
“Management and staff recognised adults at risk of or suffering harm and worked with other agencies to protect them.” from the report
Kind care
Residents generally described staff as kind. Inspectors saw staff offering practical help and emotional support.
“Residents said staff treated them well and behaved kindly.” from the report
Incident learning
Staff reported incidents, investigated them and shared learning. The home introduced body maps after incidents involving unexplained bruising.
“Managers investigated incidents and audited incidents monthly to identify any learning and actions.” from the report
Family involvement
Residents and relatives were invited to take part in reviews. The home acted on a concern about updates to relatives by offering regular emails to those who wanted them.
“Staff supported and informed families or carers as appropriate.” from the report
Blanket restrictions
seriousSome residents could not access their bedrooms without staff support and had smoking materials, money or drinks controlled by staff. Inspectors were not assured that these restrictions were necessary, proportionate or the least restrictive option.
“There were several blanket restrictions in place; however there was no policy or in place to ensure that the service was adhering to the Mental Health Act Code of Practice.” from the report
Staff training and supervision
seriousNot all staff had completed mandatory training, and some staff had received little or no formal supervision. The report also found low completion of mental health awareness and diabetes training.
“Not all staff had completed their mandatory training.” from the report
Limited activities and recovery planning
needs fixingInspectors found few meaningful activities and care plans did not include personal goals or a recovery focus. Relatives said residents often sat in the lounge during the day.
“There was little evidence of meaningful activities taking place.” from the report
Weak quality checks
seriousAudits were limited or not repeated regularly. They failed to identify problems with restrictions, medical supplies, the closed-culture review and staff training and supervision.
“Systems and processes to assess, monitor and make improvements where needed were not robust.” from the report
Unfinished and tired environment
needs fixingTwo bedrooms still had partition walls. Some communal areas needed improvement, and relatives described parts of the home as run-down and grubby.
“At this inspection, two bedrooms had a partition wall remaining.” from the report
Expired medical supplies
seriousSeveral boxes and packets of testing and first-aid supplies were past their expiry dates and had not been included in the regular medicines check.
“We found that seven out of 14 boxes of test strips for blood glucose monitoring went out of date in July 2022.” from the report
- 01Which restrictions are currently in place on bedroom access, money, smoking materials and drinks, and how is each one reviewed as necessary and least restrictive?
- 02Have the two remaining bedroom partition walls been removed, and what improvements have been made to communal and private spaces?
- 03What mandatory training and regular supervision has each staff member now completed?
- 04What meaningful activities are currently offered, and how are they linked to each resident's mental health goals?
- 05How are medicines, medical sundries and first-aid supplies checked so that expired items are not available for use?
This was an unannounced comprehensive inspection covering all key lines of enquiry and the long-stay or rehabilitation mental health ward service. This explanation was written from the published report of 14 July 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, September 2022
Sherwood Lodge Independent Healthcare was rated Inadequate and placed in special measures because inspectors found serious safety, environment and leadership concerns.
This was a comprehensive, unannounced inspection on 24 May and 1 June 2022. Inspectors spoke with patients, carers and staff, reviewed care and medicines records, and looked around the building and clinic room.
The overall rating was Inadequate. Safe and well-led were rated Inadequate. Effective, caring and responsive were rated Requires Improvement. Inspectors found damaged furniture, unsuitable bedrooms, unclear risk plans, poor incident reporting and weak systems for checking quality and safety.
There were also positive findings. Patients and families generally described staff as kind and supportive. Staff understood their duties under mental health and mental capacity law. However, the concerns were serious enough for the home to be placed in special measures. The provider sent an action plan, but inspectors said much more work was needed and the environment was not fit for purpose.
Kind staff
Most staff were described as compassionate and genuinely caring. Inspectors also observed supportive one-to-one interactions and good engagement during some group activities.
“Staff were generally committed to delivering kind and compassionate care, and it was clear that the majority genuinely cared about patients.” from the report
Family involvement
Families and carers said staff kept them informed and involved. Records showed that staff sought their views and invited them to care reviews.
“Families told us that staff supported, informed and involved them in their family member’s care.” from the report
Legal duties
Staff understood their responsibilities under the Mental Health Act and Mental Capacity Act. Patients were given information about their rights and advocacy.
“Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.” from the report
Food and independence
Patients could make hot drinks and snacks, and inspectors described the food as good quality. Staff also supported everyday living skills and community activities.
“Patients could make their own hot drinks and snacks and were not dependent on staff.” from the report
Unsafe environment
seriousThe building had broken furniture, damaged flooring and unsuitable bedrooms. Privacy, ventilation, gender separation and access for people with limited mobility were not reliably protected.
“The environment is currently not fit for purpose.” from the report
Weak risk management
seriousRisk assessments and management plans were sometimes years out of date and did not reflect incidents or changing needs. Staff were not always clear about how to reduce risks.
“Patients did not have contemporaneous and robust risk assessment and management plans.” from the report
Safeguarding and incident failures
seriousPotential abuse and safety incidents were not always reported to the right organisations or fully investigated. Inspectors could not see what learning had been identified or shared.
“Staff and managers did not take all necessary action to ensure patients were protected from the risk of abuse.” from the report
Out-of-date care records
needs fixingRecords were difficult to navigate and contained old documents. Staff could not always find the latest treatment, risk and management plans.
“All the care records we looked at contained out of date documents and staff were unable to locate up to date versions of assessments and management plans.” from the report
Unclear rehabilitation
needs fixingThe home did not clearly set out its rehabilitation model or expected length of stay. Discharge planning did not start when patients were admitted.
“The model of care for the service was unclear.” from the report
- 01What repairs and changes have been completed since the inspection, especially to bedrooms, flooring, furniture, bathroom arrangements and clinic equipment?
- 02How are current risk assessments, risk management plans and personal emergency evacuation plans checked, updated and made available to every member of staff?
- 03How are safeguarding concerns, falls, choking, self-harm and other incidents now reported, investigated and used to prevent repeat incidents?
- 04How often can patients see occupational therapists and clinical psychologists, and how is each patient's rehabilitation and discharge plan monitored?
- 05Which patients have bedroom keys, and how are privacy, dignity and same-sex accommodation protected for everyone?
This was a comprehensive, unannounced inspection of the long-stay or rehabilitation mental health service, covering all five key questions and resulting in new ratings. This explanation was written from the published report of 28 September 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Sherwood Lodge Independent Healthcare
4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Sherwood Lodge Independent Healthcare →
- September 2022Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
Read what inspectors found at Sherwood Lodge Independent Healthcare →
- July 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2015
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 10 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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23 live-in carers within about an hour of North Somerset
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,050 to £1,320 a week. 19 can care for a couple. 12 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.