Sheerwater 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 requires improvement. This meant the provider did not have clear and effective governance, management and quality assurance arrangements.

The service was in breach of legal regulations in relation to governance.

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 shared vision and culture based on transparency, equality and human rights, diversity and inclusion, and understanding people’s individual needs.

Leaders and staff understood the importance of working in an open and transparent way. Staff respected the rights of the people they cared for and one another.

Staff told us the owner of the home and the registered manager were supportive and available for advice and guidance when they needed it. Relatives said leaders and staff communicated with them well and kept them up to date about their family members’ health and wellbeing.

The provider had inclusive leaders who understood the context in which they delivered care and support, and embodied the values of the organisation. Leaders had the skills, knowledge, and experience to lead effectively. They did so with integrity, openness and honesty.

People told us they saw the owner of the home and the registered manager most days and said they were approachable and responsive. One person told us, “[Registered manager] is approachable, and I get on well with [the owner of the home].”

Relatives said the owner of the home and the registered manager demonstrated a caring approach, and were available if they needed to discuss any aspect of their family members’ care. One relative told us, “[The owner of the home] and [registered manager] are wonderful and always on the end of the phone.”

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

People told us they would feel comfortable speaking up if they were dissatisfied, and were confident any concerns they raised would be listened to. People who had complained in the past said the provider had responded appropriately to their concerns. One person told us, “I would say if I felt unhappy about something. I would speak to [member of staff]. She is very good and would listen to me.” Another person said, “I would feel comfortable making a complaint, I would tell the management. I’ve done it a couple of times. Things were sorted out pretty quickly when I complained.”

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.

Staff told us the provider and the registered manager treated them and their colleagues fairly and equitably. They said the provider and the registered manager respected their rights and cared about the staff who worked for them.

The provider did not operate or maintain effective quality monitoring and governance systems. Records were not always accurate or up to date, which meant the provider had limited assurances about safety and quality.

Quality monitoring process did not always identify risk or areas where improvements were needed. For example, medicines audits were carried out but had not identified the shortfalls relating to medicines management we found during our visit.

Some records lacked important information which would be essential in certain circumstances to keep people safe. For example, the provider’s business contingency plan did not include information about alternative accommodation provision in the event of an emergency which rendered the home unliveable.

Some records were not being maintained accurately or were out of date. For example, information about people's dietary needs on a notice board in the kitchen included the dietary needs of a person who no longer lived at the home.

In some cases, records did not evidence that people were receiving the care outlined in their care plans, or that staff had attended the training they needed. One person required regular repositioning by staff to reduce the risk of pressure damage. Staff informed us that repositioning was carried out in line with the person’s care plan. However, this was not being recorded.

We observed that staff supported people safely and effectively during our visit, and staff confirmed they had attended training relevant to their roles. However the training record did not reflect this, which meant the provider was unable to demonstrate that staff had attended the training.

The local authority carried out a quality audit of the service in April 2024. Overall, the outcome of the audit was positive although some recommendations for improvement were made, including around record-keeping in relation to checks and audits. Our findings at this assessment indicated these recommendations had not been promptly implemented, as the shortfalls we found had not been identified by the provider’s own quality assurance processes.

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

The registered manager and staff had established effective working relationships with other agencies and professionals, including local authority quality teams, commissioners, and healthcare professionals. Feedback we received from a professional stated, ‘[The owner of the home] is very involved, which is good, and [registered manager] is always responsive.’

The provider aimed to learn from events such as accidents and incidents. Staff told us any learning from events was shared with them to improve practice and standard operating procedures.

Staff told us they had opportunities to contribute to the development of the service and that any suggestions they made for improvements were listened to.

The provider had plans to use technology to improve outcomes for people. the management team told us an improved digital care planning system had been commissioned and would be introduced in the near future.