Sherbutt House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to outstanding.

This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 89 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The culture of the service was very positive, person-centred and inclusive. The management team and staff worked well to provide safe, high-quality, compassionate care. Managers lead by example and created a trusting environment, where learning and improvement was strongly promoted. Staff were clear about their role in ensuring people had a good quality of life.

There was a clear vision, values, and strategy developed in collaboration with staff, people who used the service and stakeholders. The provider monitored and reviewed progress against their plans and acted when they identified any issues.

Staff understood the vision and values of the home. One told us, "Keeping clients safe and ensuring their happiness. Making sure they have a good life and that they are safe. I think this is the main focus. Running a service for the users and meeting those needs are important." Another told us, “The service offers a really nice home for our clients. They are all happy and there is a nice atmosphere.”

The provider had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

There was a very robust management structure, which included regular on-site presence from the directors of the company, along with a registered manager and duty management cover throughout the week. As a family run business, the directors and management team each focussed on different aspects of service delivery and were very available to the staff team.

The provider promoted training and development opportunities for staff to progress within the organisation. This included management staff who had achieved level 4 and 5 qualifications, and staff who had been enabled to change roles to further develop their skills and careers.

The registered manager was passionate about providing high quality care and advocating for people who used the service. Staff spoke very positively about the management of the service. They told us, “The managers are great, fantastic and supportive" and, “This is a great family orientated place to work... Any problem you can go to anyone. Managers are amazing, anything I’m stuck on they will talk me through it." People who used the service knew the registered manager well and were able to discuss any concerns with them.

The registered manager kept up to date with best practice. They attended regular provider events and on-line networking forums. They were very knowledgeable and keen to continually learn. They had been nominated as ‘Hero of the Year’ in a regional awards event, and the company had won family business of the year awards.

External professionals spoke highly about the management of the service. One told us, “The service is very well managed by [registered manager] and the team…In my opinion Sherbutt House is an exceptional service and they should be proud of the service, care and dedication they provide.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Information about whistleblowing and how to report safeguarding concerns was available to staff. They understood the processes for raising issues and felt able to speak up without hesitation. Staff were confident the management team would take any concerns seriously and act on them promptly. This supported an open and transparent culture.

The provider made some improvements to their whistleblowing policy in response to our feedback. The amendments helped to ensure there were other impartial sources of support available to staff, should they ever have a situation where they felt their concerns had not been heard.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had recruitment, selection, and equality and diversity policies designed to promote a fair, inclusive and non discriminatory workplace. The provider told us they recruited a diverse workforce, and progression opportunities and training were advertised openly, to promote transparency and equal access.

The service had a positive disability access rating, following an external audit of the premises. This meant the environment met standards of accessibility. Where staff had specific needs or required reasonable adjustments to help them perform in their role, they were supported. Alternative seasonal parties were arranged which staff could choose from, to support inclusion around social preferences and neurodiversity.

No concerns were raised about any discriminatory practice and staff felt well supported.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The management team carried out a comprehensive range of regular audits, checks, feedback and observations to monitor the quality of the service. This included daily management walkarounds, which considered various aspects of care delivery and the environment. Action was promptly taken when any shortfalls were identified, and the provider was very proactive about seeking opportunities to learn and improve.

Overall, the governance and audits were effective and used to successfully drive improvement. However, during our assessment we found some issues that had not been identified and addressed through the provider’s own governance systems. This included issues in relation to medicines and some care delivery records. The provider advised us that some of the gaps in medicines records had only occurred very recently, due to an issue with the provider’s electronic system removing certain records, so this issue had not yet been picked up in the monthly audits. Medicines storage temperature checks were also affected by a technical issue. However, other issues were more long-standing, so the provider adapted their audits and put relevant measures in place to ensure issues like this would be promptly identified moving forwards. The provider took comprehensive action and demonstrated commitment to ensuring robust systems.

The provider submitted required information to CQC in a timely way, about relevant incidents at the services. The management team were knowledgeable about regulatory requirements.

The provider clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

The provider worked very positively with a range of other professionals and services to ensure people’s health and wellbeing needs were met. We received consistently positive feedback from external professionals about partnership working with the service. They felt staff were responsive to any guidance they provided and one commented that the registered manager took a “very cooperative approach” and was open to listening to suggestions. External professionals told us staff always ensured appropriate information was available to them.

The home was located in a residential area and people accessed a wide range of facilities in the local community on a daily basis. The service also hosted a monthly disco in a community venue, which was open to all. The registered manager told us this was very popular and much enjoyed. This helped to foster positive community relationships.

The provider also shared examples of good practice, people’s achievements and events via social media and in the local community.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider always looked for ways to improve the service for the benefit of people. For instance, commissioning a nutritionist to review menus at the service and developing ‘About Me’ videos with each person, to reflect their care plan needs and preferences. The management team placed a strong focus on listening to people’s views to improve and develop the service.

Since our last assessment the provider had significantly invested in a range of digital systems, aimed at improving care planning and compliance monitoring, along with freeing up staff time to be able to deliver care. In addition to care planning software with AI support, the provider had worked with a developer to create a bespoke system for the service. They also tested new functionality within care planning software and worked with the local authority to share learning about digital systems with other providers. The provider had commissioned an independent cyber security vulnerability assessment, to ensure the security of its systems.

The provider also demonstrated commitment to continual improvement through other projects they had worked on. For instance, they had commissioned an external specialist to measure the service’s carbon footprint and make recommendations for reducing their environmental impact. This showed the provider considered their wider impact in the community.

The provider also contributed to care provider forums to build relationships and exchange ideas and good practice. Throughout the assessment process the management team demonstrated they were very keen to learn and develop their systems in response to any feedback.