Sherbutt House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff completed clear records about any accidents and incidents, and the management team reviewed these incidents to identify and take any action required to reduce the risk of similar incidents occurring again. The registered manager completed monthly reports to identify any patterns or further action required in relation to accidents, incidents and near misses. Learning points were shared and discussed with the staff team. Any safety issues were also identified and addressed promptly via the provider’s auditing processes.

People and relatives were also involved in discussions about any changes which may be required to people’s care as a result of incidents. One relative told us, “There's lots of communication with us. Nothing is concealed from me. When anything happens, they let me know, and we are always involved in the solutions.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Strong partnerships with external professionals ensured safe transitions for people moving into the service and smooth processes for those moving on. Managers and staff were knowledgeable about the role of other agencies and professionals and made appropriate referrals for support where required.

The registered manager provided positive examples where they had worked with people and their families to ensure people’s move into the home was managed sensitively, safely and at a pace which worked for the person.

Important information was readily available to support people in the event of a hospital admission.

The provider worked with people to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider had robust safeguarding systems in place. There was a safeguarding policy and staff completed regular safeguarding training. Their knowledge and understanding in this area was routinely checked by the management team. Staff were aware of the signs of potential abuse and understood what action to take if they had any concerns, including how to report concerns externally if required.

Applications were submitted where necessary to lawfully deprive people of their liberty. Staff complied with all conditions of Deprivation of Liberty Safeguards authorisations, ensuring that actions taken were proportionate, least restrictive, and in people’s best interests.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff completed comprehensive risk assessments and kept these under regular review. Risks were considered in relation to a range of topics, such as nutrition, falls, skin integrity, and individual health conditions like diabetes.

Staff demonstrated a good understanding of people’s needs and any potential risks affecting them. They were aware of the support each person required to keep them safe, whilst living a full life. We observed staff were attentive to people’s safety and wellbeing.

Relatives felt people were safe and we observed people appeared comfortable. A relative told us the support provided gave their loved one “safety and security.”

Staff understood when people communicated distress or anxiety through their behaviour and non-verbal communication. They responded promptly and appropriately.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider completed regular checks of the property and equipment, and relevant safety certificates were in place. The property was well maintained, and any issues identified were promptly rectified. Fire safety systems were in place, and the provider followed advice from fire safety specialists. There were personal evacuation plans to safely support people evacuate in the event of a fire.

The home was designed and arranged to promote personalised care. It comprised four distinct areas, each with individual bedrooms and shared kitchen and living spaces. People’s preferences, compatibility, and any identified risks were taken into account when determining which area of the home was most suitable for them.

One person told us they had recently had a new shower fitted which was more suitable for their needs, with handrails which they found reassuring. A visiting professional told us, “The buildings are well kept, secure in terms of entry and signing in, and there is an overall calm feeling of people knowing what they are doing.”

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

People, relatives and external professionals were highly complimentary of the staff team. Comments from relatives included, “There's a core of staff that have been there as long as [Name] has been there…They are just wonderful,” “The staff are brilliant” and, “They are very proactive and on the ball.”

Staffing arrangements were exceptionally person-centred. People were supported by a well-established and experienced staff team, who were excellently supported and trained. Consistent staffing was arranged for each area of the home, wherever possible. This ensured people were supported by familiar staff who knew them well. Staffing was organised and tailored to people’s needs. For instance, one person had a staff member who had been specifically employed and matched to support them to attend a regular activity they enjoyed.

Staff were safely recruited, using a values-based approach, and the provider had a waiting list for future recruitment. There were robust contingency arrangements in place, in the event of any unplanned staff absence. The Registered Manager and a duty manager were also additional to the core care rota each day, which ensured leadership presence and the availability to support the team when required.

Staff had the skills and knowledge to support people as they received a comprehensive induction, which included getting to know each person. They also completed a range of training, to support people’s individual needs. Staff undertook immersive experiential training relating to dementia and autism. This can help staff understand what it feels like to live with particular conditions by simulating sensory, cognitive, and emotional challenges. A number of staff were ‘champions’ in particular areas of practice and had responsibility for promoting best practice in these areas.

Staff were highly satisfied with the support they received. An external professional commended how well staff engaged in training opportunities. They had trust in the provider and staff to pilot new training courses with them. This meant people using the service benefitted from well trained staff.

Staff received very comprehensive supervision and annual performance reviews, and development opportunities. There was a mentoring scheme, whereby all staff had a mentor for additional support and practical advice. There were also a range of incentives to support with staff recognition and retention.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and were aware to share concerns with appropriate agencies promptly.

The home was clean and there were no malodours. There were cleaning schedules in place and housekeeping staff were employed to support with ensuring the environment was effectively cleaned and hygienic. The provider had infection prevention and control (IPC) policies and procedures in place, and staff followed best practice. Staff received regular training refreshers and routine observations of their practice in this area, including handwashing.

There was a schedule of audits relating to IPC, to ensure continued compliance. Improvements were made as a result of these audits to improve consistency of staff practice. Information about good cleanliness and infection control practices was also shared with people using the service.

Medication administration records were fully completed. All stock levels were correct and running balances were in place for each person. If medicines were taken out of the property, such as for day trips, these were signed out and signed back in when returned.

Although monthly audits were undertaken and errors and incidents reviewed, these checks had not identified some issues we found during the assessment.

Controlled drugs, which require extra precautions due to their potential for abuse and misuse, were reviewed by a manager as part of daily walkarounds. However, the stock level checks were not entered into the controlled drugs register, and a second staff member was not present during these checks, which does not align with best practice.

Temperature monitoring was completed automatically via an electronic system. However, records showed the medicines fridge had gone outside the required range, and this was not picked up on. Therefore, we could not be confident that medicines requiring refrigeration were always stored safely. A manual thermometer was added promptly, and replacement stock was sourced to ensure that only medicines stored safely within the correct temperature range were administered. Additional checks were put in place.

We identified instances where medicines were not administered at the prescribed times, posing a potential risk to the person’s health. Staff told us this occurred due to the individual’s personal care routine. The GP was notified, and additional guidance was issued to staff to ensure timely administration going forward.

People that were prescribed as and when required (PRN) medicines did not always have in depth protocols to ensure staff would know how and when to give these appropriately. If someone was prescribed a variable dose, such as 1 to 2 tablets, it was not clear when to give what dose and when to escalate. This was rectified promptly.

Records to support the safe application of topical creams and patches were not always in place. This was addressed straightaway by the provider.