Archived: Pro-Care Dispersed Housing Ltd - Sherbourne Lodge

A registered manager was in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

At the last inspection on 22 April 2015, the service was rated ‘Good’. However, we found during this unannounced inspection, on 23 August 2017, concerns and a breach of regulations.

During this inspection, we found issues with how people’s medicines were stored and recorded. There was a miscount of medication given and recorded stock that remained. Medicines, including controlled drugs, were in unlocked cupboards in an office left unattended for long periods. This meant anyone, including members of the public, could access dangerous medicines. This demonstrated the registered manager did not always protect people from the unsafe management of their medicines. They did not have clear oversight of procedures and recordkeeping. This is a breach of Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe care and treatment.

You can see what action we told the provider to take at the back of the full version of the report.

People were encouraged to complete surveys to check their satisfaction levels with the service. The registered manager, staff and those who lived at the home worked closely together on a daily basis and held regular meetings. This meant any issues could be addressed immediately. The registered manager had a range of systems to retain oversight of the home and maintain everyone’s safety and wellbeing.

Care records we reviewed contained risk assessments to guide staff about protecting people from potential risks of inappropriate or unsafe support. Staff received safeguarding training to underpin their knowledge about protecting people from abuse or poor practice. People told us they felt safe and secure whilst living at Sherbourne. One person said, “I feel settled and safe here.”

The registered manager acquired necessary documents to ensure staff were fit and proper persons before they commenced in post. People told us staffing levels were sufficient to meet their needs. Staff had completed a range of training to assist them with their development, skills and understanding.

Staff had a good understanding of the principles of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards. Staff worked collaboratively with people in discussing and agreeing their care plans. Those who lived at the home said they felt free and able to come and go as they pleased.

All staff who prepared food had completed food hygiene training to assist them to maintain food safety standards. The registered manager had systems, such as weight checks and risk assessments, to reduce the potential risk of malnutrition.

It was evident to us people were relaxed and felt able to interact with staff with ease and in a familiar, friendly way. One person told us, “The staff are good with me.” Care records we looked at evidenced people were fully involved in agreeing and developing support plans.

Staff completed people’s records with a person-centred approach. They had a good level of information about each person’s self-caring skills and the support they required. The registered manager had further guided staff to assist people to maintain their independence.

We spoke with a range of people about the home. They included the registered manager, staff members and people who used the service. We also asked for the views of external agencies in order to gain a balanced overview of the service provided by Sherbourne Lodge.

People who use the service told us they were happy with the support they received. One person said, "I have been here a long time. I like it here. I have no problems" People told us their needs had been discussed and they had agreed to the support to be provided. They told us their carers provided flexible support and they felt well cared for.

People experienced care, treatment and support that met their needs and protected their rights. People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

We found that some of the kitchen cupboards had fallen apart following a water leak; that paint had flaked off one of the kitchen walls; and some of tile work around the sinks needed to be replaced. The state of this equipment was found to be unsafe and unsuitable as they posed risks to people's general safety. We found the bathroom to be a cold and uninviting room. The walls were bland, and all that was in the room was a bathroom and toilet. We spoke to people about the bathroom Staff and people living at the home agreed that the bathroom needed to be decorated. People living at the home thought that the installation of a shower above the bath would be useful. There had been delays in responding to these reviews, leaving equipment in need of repair and replacement.

People told us they could express their views and were involved in decision making about their care. They told us they felt listened to when discussing their care needs. One relative spoken to said, 'It's the best place for him, they are good to him.'

People living in the home said they felt that they were safe at Sherbourne Lodge. They said staff were approachable and kind and they could talk to them.

Residents told us the staff team were friendly and supportive. They said routines were flexible, they could come and go as they please. One person also said they could get up and go to bed when they wished.

People who used the service told us staff treated them with dignity and respect. We saw evidence of this when observing interaction with the staff member and residents. This included staff knocking on doors before entering and speaking to people using their preferred name.