Sheerwater 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 changed to requires improvement. This meant some aspects of the service were not always safe and there was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to the management of medicines.

This service scored 62 (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 positive culture of safety based on openness and honesty. Lessons were learned to identify and embed good practice.

Leaders and staff listened to concerns about safety and investigated and reported safety events. Any accident and incidents that occurred were recorded and reviewed to identify action that could be taken to prevent a recurrence.

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

People received their care from a consistent staff team once they moved into the home. The registered manager and several of the staff team had worked at the home for a number of years.

People told us they knew the registered manager and staff well, which they said was important to them as it had enabled them to establish good relationships with the staff who provided their care.

Relatives also highlighted the importance of consistent staffing in their family members’ experience. One relative told us, “[Family member] loves her main carer, and she is very fond of [another member of staff]. She talks about them when she stays with us.”

The provider worked with people to understand what being safe meant to them and the best way to achieve that. Staff focused on protecting people’s right to live safely, free from harassment, abuse, discrimination, avoidable harm, and neglect. The provider shared concerns quickly and appropriately.

Staff attended safeguarding training in their induction and regular refresher training thereafter. Staff were able to describe the potential signs of abuse and how they would report any concerns they had. One member of staff told us, “If I was to see something wrong, or a resident told me something, I would act on it and tell management, and if no action was taken, I would go to CQC.”

The provider worked with the local authority and other agencies to investigate when safeguarding concerns were raised. This included contributing to safeguarding enquiries and providing information when requested.

If people were subject to restrictions for their own safety, applications had been made for Deprivation of Liberty Safeguards (DoLS) authorisations, and these were only implemented when they were 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.

People told us they felt safe at the home and when staff provided their care. They said staff helped them manage any risks, such as risks associated with mobilising. One person told us, “I like it here, it feels very safe.” Another person said, “I am quite happy here; you are looked after properly.”

Assessments had been carried out to identify any risks in people’s care. Where risks were identified, plans were put in place to mitigate them. We saw staff providing people’s care in line with their support plans to keep them safe.

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 carried out health and safety checks to ensure the environment was safe. These checks included regular testing of fire safety systems and equipment.

Although the environment was safe, some aspects of the building required repair or refurbishment. For example, we found a threadbare carpet and a stained wall in one person’s bedroom. A wall fixing for a radiator cover in a corridor had come loose, and a handrail had become detached from a wall but had not been refixed.

Some of the relatives we spoke with said the environment needed improvement, although felt this was compensated for by the care their family members received. One relative told us, “It is a little bit rough around the edges, but we think that is made up for by the care. It may not look amazing, but they do treat [family member] as part of the family.” Feedback from another relative stated, “It looks a bit tired inside and out but it feels really homely and caring.”

There were always enough qualified, skilled and experienced staff available to meet people’s needs and keep them safe. People told us staff were available when they needed them. They said staff had time to spend with them other than when they were providing their care, and this was confirmed by our observations. One person told us, “There is always someone around, and the carers have time for you.”

Staff understood the importance of engaging with the people they supported and said they worked well together to meet people’s needs. One member of staff told us, “There is enough staff. We support each other. We spend as much time as we need with the residents. If we rush, we cannot do a good job.”

Staffing levels were planned according to people’s assessed needs. The registered manager told us the dependency tool was reviewed whenever people's needs changed or a new resident was admitted.

Staff were recruited safely and had access to the induction and training they needed for their roles. Staff told us their induction had included shadowing experienced colleagues to get to know people and their needs. Staff attended training in line with the Care Certificate,a framework of 16 standards designed to ensure care staff have the necessary skills, knowledge, and behaviours to provide compassionate, high-quality care.

People told us they were happy with the cleanliness of the home and said housekeeping staff cleaned their rooms were regularly. One person told us, “I am happy with the cleaning. My room is cleaned regularly.” Relatives also felt the home was kept clean. One relative said, “I think the cleanliness is fine; [family member’s] room is kept clean.”

Although people told us they were happy with standards of hygiene, we found cleanliness in some parts of the home would benefit from improvement. We noted that 2 of the 7 staff surveys dated January 2025 indicated the home was not always as clean as it should be. We shared this feedback with the registered manager.

Medicines were not always managed safely or administered as prescribed. The provider’s systems and processes were not effective in ensuring correct administration and accurate recording.

One person had been prescribed emollient lotionsfor dry skin and abarrier cream to protect their skin from moisture-related damage. The person’s medicines administration record (MAR) contained a number of gaps over previous weeks, which meant we could not be assured these topical medicines had been administered.

Another person’s MAR contained a number of gaps for a laxative medicine. Staff told us the person often refused the laxative as they did not need it. Best practice guidance on managing medicines in care homes states that, when medicines have been refused, staff should record the refusal on the MAR rather than leaving a blank entry, which indicates administration has been missed.

One person used a pain-relief patch, which needed to be applied in a different place on their body each week. The person’s MAR advised staff to ‘Check patch chart’ before administering a new patch to ensure they placed it on a different part of the person’s body from the existing patch. However, no chart was being maintained, which meant it was not possible to confirm the patch site was being rotated.

Where handwritten entries had been made on MARs, these had not been double signed, which did not comply with good practice guidance. Medicines in liquid form did not have the date of opening recorded.

Stock checks were not carried out regularly and balances were not routinely recorded, which meant the provider could not be sure medicines were being managed safely. The checks we carried out during our visit found some discrepancies between the number of medicines in stock and the number of medicines which should have been in stock.

Medicines audits had not recognised or recorded any concerns with medicines management, which meant they were not effective in identifying shortfalls.

Some aspects of medicines management were operated safely. Each person had an individual medicines profile and there were individual protocols in place for medicines prescribed ‘as and when required’ (PRN). The administration of any controlled drugs was double-signed, and the remaining balance recorded.