Sherwood Lodge Independent Healthcare

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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.
 

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 clear vision, strategy and culture which was shared by the team. 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 service was open and inclusive and focused on supporting people to achieve a good quality of life. The provider stated they promoted recovery principles and focused on individuals and emphasised their strengths and autonomy through enabling independence.

The registered manager and several members of the team had worked at the service for many years, and staff at all levels were proud of the organisation and the culture. One staff member said, “The team is so good. We are all starting from the same place, we just want the best for people.”

The registered manager and senior staff led by example. Staff and people told us they were visible and approachable. They were comfortable speaking with them, raising concerns and making suggestions. Staff told us, “I always make suggestions and they listen to me” and “We’re well supported. If you have a problem, you can always take it to [registered manager].” Along with registered manager oversight, this helped ensure the service delivered safe, high-quality care which reflected its vision and values.

The provider had 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 did so with integrity, openness and honesty.

The registered manager and senior staff team had all worked at the service for several years. People, relatives and staff knew them well and spoke highly of them. Staff used terms such as ‘brilliant’, ‘supportive’ and ‘helpful’ to describe the registered manager. A professional described the registered manager as, “A fierce advocate for her residents.” A member of the leadership team was always visible around the service and led by example. They were well known by everyone who had contact with the service.

The registered manager was experienced and had the skills, knowledge, experience and credibility to lead effectively. They were clear with staff about changes, shortfalls or improvements which were needed and worked with staff to manage these. Feedback from staff and records of meetings and handovers confirmed this.

The registered manager understood their responsibilities and notified the local authority and CQC of incidents or concerns as required.

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

Systems were in place for people to speak up and raise concerns or make suggestions. The registered manager kept a log of complaints which demonstrated themes and outlined the response to concerns. Relatives told us they would be confident in raising concerns and felt they would be taken seriously. Most added that they had never needed to complain.

Staff were able to speak up if they had concerns and told us they could talk to the registered manager or provider directly if needed. A ‘Speak Up Guardian’ had been appointed to provide staff with guidance and support. Staff told us the registered manager was responsive, supportive and made changes where they could. Comments from staff included, “I am learning every day. We use reflective practice a lot” and “We learn and that way we make things better for people.”

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 were positive about their colleagues and the team was diverse, made up of individuals from a wide range of backgrounds, ages and experience. One staff member said, “We’re all different, but everyone in the team knows what to do. We get on and I really trust the team.”

Staff told us they had been supported when they needed adjustments because of personal circumstances, for example with childcare needs or personal illness.

The provider had policies and procedures in place regarding equality, diversity and inclusion and staff had received relevant training.

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.

Since our last inspection, improvements had been made to quality monitoring systems at the service. Some audits and checks had been re-designed to improve how inconsistencies or shortfalls were identified and recorded. Forms included information about why the audit was being carried out and linked checks to standards and guidance. These changes helped to improve the quality and safety of the service.

Audits were effective in identifying areas in need of improvement. Action plans were included in most audits and improvements were followed up. Staff told us when areas for improvement were identified through audits, this was discussed with them in handovers and team meetings.

The registered manager was considering reintroducing an overall service development plan to support effective monitoring of the service and clearly show improvements made.

Staff told us they felt the service was well run and understood their responsibilities in keeping people safe and providing them with effective, person-centred care.

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 management team had good relationships with other organisations and professionals to ensure people received effective support and joined up care. Professionals gave positive feedback about the service. One professional told us, “Staff always provide any information I need and keep me updated if there has been any significant incidents or illness. The paperwork is always well documented and if I ask about anything, it's answered well.”

Where possible, staff supported people to access community resources such as local shops, leisure facilities and outdoor spaces. Staff had recently organised visits to garden centres and museums and regularly took people to local parks and cafes.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They 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 team had made significant improvements to the service since our last inspection. The registered manager was open and transparent during the inspection. They engaged with other providers to share knowledge and experiences. The team was open to feedback and committed to continuing to improve and develop the service.

The provider invested in improvements such as physical changes to the service and new electronic systems for recording care.