Sherdley Manor

We found the following examples of good practice:

Face to face visits had been suspended to ensure residents and staff remained as safe as possible. However, the home was preparing for face to face visits in accordance with current guidance. People were able to keep in touch with their loved ones in other ways such as telephone calls and window visits.

Staff did not work at other homes and agency staff were only used in emergencies. Staff breaks were limited to two at any one time to reduce the risk of cross-infection.

The home was limited in space. There were areas for personal protective equipment (PPE) to be put on and removed safely. We saw staff wearing PPE correctly and maintaining social distancing where possible. We referred the home to guidance regarding specific designated areas for PPE and ways to enhance social distancing of residents.

Cleaning schedules at the home had been reviewed and enhanced. This included regular cleaning of frequently touched surfaces throughout the day. Clinical waste was managed safely and in line with the national guidance.

The home had a regular testing programme in place for staff and residents. A vaccination programme was also underway.

Further information is in the detailed findings below.

Sherdley Manor is a care home that provides personal and nursing care for up to 23 people aged 65 and over. Twenty-one people were living at the service at the time of this inspection.

People’s experience of using this service:

Improvements had been made since the last inspection so that mental capacity assessments and best interest decisions were completed in line with the Mental Capacity Act (MCA). People’s needs and wishes were assessed and planned for. Care plans identified the intended outcomes for people and how their needs were to be met. People received care and support from appropriately trained staff. People were offered a nutritious and balanced diet and their healthcare needs were understood and met.

Systems for assessing and monitoring the quality and safety of the service were more effective in identifying areas for improvement within the service. People, family members and healthcare professionals described managers as approachable and supportive. Systems were in place to gather people’s views on the service.

We have made a recommendation about the management of medicines. People were protected from abuse and the risk of abuse and staff understood their role in relation to this. People and their family members told us that the service was safe. Risks to people and others were identified and measures put in place to minimise harm. Good infection control practices were followed to minimise the risk of the spread of infection. Regular safety checks were carried out on the environment and equipment.

Staff were knowledgeable about people’s needs and how they were to be met. People told us they received care and support in line with their care plan. People and their family members knew how to raise a concern or make a complaint about the service.

People were treated with kindness and respect by staff who knew them well. Staff provided care and support in a calming, relaxing manner with positive outcomes for people.

Details are in the key questions below.

Rating at the last inspection: Required Improvement (report published on 22 November 2017).

Why we inspected: this was a planned inspection based on the rating of the last inspection. The rating for this service has improved to good overall.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received we may inspect sooner.

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Sherdley Manor is registered to provide accommodation and personal care for up to 23 older people. At the time of the inspection the service was full. The service also provides support to people living with dementia.

The service had a registered manager who had been registered with the CQC since November 2014. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During the inspection we identified breaches of Regulations 11 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Audit processes were in place, however these had not identified some of the issues that were found during the inspection. The medicines audit had not identified that protocols were not in place for people prescribed ‘as required’ (PRN) medication to inform staff about when this should be given. They had also failed to identify that the process around covert medication had not been followed. Whilst this issue had not had an impact on people’s wellbeing, there remained a potential impact of misadministration of medication.

Mental capacity assessments (MCA) and best interests decisions had not been completed as required for people living at the service. For example, it had been determined that two people needed to remain in their bedrooms. However, an MCA had not been completed to determine their capacity to consent to this, whether this was in their best interests or the least restrictive approach possible. This had the potential to infringe upon people’s rights and liberties. This showed that the registered provider and registered manager did not have sufficient knowledge around the requirements of the Mental Capacity Act 2005. We raised this with the registered manager for her to address.

A majority of interactions between staff and people using the service were positive. Staff spoke kindly, with respect and were mindful of maintaining people's dignity. However, In one example we identified that a majority of the interactions being completed for one person were mainly task-focussed. Because of this we have made a recommendation to the registered provider around meeting the social needs of those people living with dementia.

Staff had received training in the majority of areas needed to carry out their role effectively. For example, moving and handling, fire safety, the Mental Capacity Act 2005 and DoLS. The registered manager confirmed that staff were being supported to undertake training in managing challenging behaviours for those people who demonstrated behaviours that challenge. This helped to ensure that people were provided with the care and support they needed.

Staff were aware of how to report any safeguarding concerns they may have and they had received training in safeguarding vulnerable adults. This helped to ensure that people were protected from the risk of abuse.

The registered provider had robust recruitment processes in place which helped ensure that staff were of suitable character to work with vulnerable adults. Checks had been completed as part of the employment process to ensure that staff did not have a criminal record and were not barred from working with vulnerable groups.

People received a diet that was appropriate to meet their needs. Staff were aware of those people with special dietary requirements and they ensured these needs were met. The kitchen was well-stocked with fresh and tinned produce for people’s meals.

People were supported to access their GP or other health professionals as required. Care records showed that staff had been proactive in raising any concerns about people’s health and wellbeing. This helped ensure that people’s health was maintained.

Each person had a care record in place which outlined what staff needed to do to support them. This was tailored to each individual’s needs, such as the support they needed with their mobility and during personal care tasks. These records also contained information about people’s personal histories and preferences. This helped staff get to know people and their support needs.

There was a complaints process in place which had been followed. The complaints policy was available to people and their families, and people’s family members confirmed that they felt able to raise concerns with the registered manager. Complaints records showed that responses to people’s concerns had been given in a timely manner.

We carried out a tour of the premises and saw that it was unsafe in some areas. We observed some of the corridor flooring to be torn and in one area tape had been used to secure the laminate flooring, which created a trip hazard. The outside grounds had some unsafe and potentially dangerous areas including, trailing electric cables (across the ground and hanging from the building), disused old mattresses stored alongside the maintenance shed, barbed wire on part of the perimeter fence and unused concrete posts (overhanging onto a public pathway). A few trip hazards were also identified and the manager was informed of these (exterior door and part of the path). The outside grounds in general were unsightly, with building rubble and litter visible to the outside public.

We observed that up to date fire extinguishers and portable appliance checks had been carried out and were found to be suitable and safe to use.

Some of the people living in Sherdley Manor during our inspection had complex needs which meant they were not able to tell us their experiences. Two people, when asked if they felt safe? They replied yes. We saw members of staff positively interacting with people who lived in the home. People were treated with dignity and respect. In discussion and in observation, we saw that people were relaxed and at ease with the care staff.

We looked at how the service managed the control of infection. We found some aspects of this area to be unsafe.

Is the service effective?

We spoke with the members of staff who were on duty throughout the day and they all demonstrated that they had a clear understanding of people's needs and how to meet them.

We saw that some staff training was not always up to date or relevant to meet the needs of the people living in the home. For example, there was no evidence of dementia training or dignity and respect training having been provided.

The formal supervision of staff had not been regularly provided. Although staff said they felt supported by the manager and could approach the manager with any issue or concern.

We found that people's health and care needs had been appropriately assessed, with peoples care plans being detailed and the newly reviewed care plans being more person centred and individualised.

Is the service caring?

During our inspection we observed that staff were attentive, caring and enthusiastic about meeting the needs of people who lived in Sherdley Manor. We saw people positively responding to members of staff, which showed that a good rapport existed between them. We saw that people were treated with dignity and respect by the staff.

Some of the staff comments were, 'absolutely love working with older people' and 'We (staff) are trying to arrange for an entertainer to come in at least once a month'.

Is the service responsive?

During our inspection we observed that people received appropriate care, treatment and support when they needed it. We saw people being encouraged and assisted by the care staff.

The care files we reviewed demonstrated that people who lived in the home had been supported to express what was important to them and we saw evidence of family members being contacted and consulted regarding a person's health, hospital appointments and GP visits. The manager informed us that no complaints had been received since our last inspection.

Is the service well-led?

The manager of the home had been in post since February 2014, although not yet registered with the commission (CQC). It was clear that some improvement regarding the daily running of the home had taken place since the new manager had arrived.

Sherdley Manor had limited quality assurance monitoring processes in place. No quality assurance monitoring surveys had been provided to people living in the home or their representatives. The manager informed us that the organisation is developing a more up to date questionnaire survey and once finalised it will be provided to the relevant people.

We saw a copy of the minutes from a seniors meeting that had recently taken place and we saw an agenda for a forthcoming care staff meeting.

Some of the staff comments were, 'It's so much better with the new manager' and 'We are a better team now, we all chip in and work together'.

Some visitors to the home said, 'The new manager seems very nice and interested in the residents' and 'I am quite impressed with the home and the way it is run'.

We were informed by the local authority's contract monitoring unit, that they had seen some positive changes with the new manager and especially the updated and improved care plans.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences. We gathered evidence of people's experiences by reviewing surveys, which had been provided by some of the relatives.

During our inspection we observed positive interactions between members of staff and people living in the home. We saw members of staff speaking to people in a calm and sensitive manner and encouraging people to get involved in different activities.

We looked at people's care and medication records, which we found to be satisfactory, appropriate and up to date.

A new manager had been recruited and we found a number of environmental improvements at this inspection (June 2013).

We looked at training and supervision records for staff, which demonstrated that members of staff had received relevant and appropriate training. The provision of supervision had increased since our last inspection.

The staff were all positive about the changes that had taken place since February 2013. The atmosphere in the home was relaxed, calm and the feedback received from relatives surveys and staff was that people living in Sherdley Manor were happy, content and safe.

We spoke with a health professional, who was visiting the home to provide some treatment to a person living there. The feedback was positive with some of the comments being, 'Girls are really helpful and if we ask them to do anything, they do it' and' I am coming here everyday at the moment. The manager is really helpful'.

We spoke with some relative's at the inspection and afterwards via telephone. Some of the comments were,' We really think that (name) is much better off living at the home,' 'Not much going on here, no activities. I don't think people are stimulated' and 'The girls (staff) do well. It's good to hear that they are getting another cleaner'.

We spoke with five members of staff looked at staff training and supervision records. We looked at care records and carried out a tour of the premises.

We gave feedback regarding our findings to the manager following our inspection.