Sherborne Court Neurological Centre

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 requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 56 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice Although accidents and incidents were recorded, reviewed, and discussed with staff through daily flash meetings and other forums, evidence of the resulting learning and improvements was not consistently documented. We found some incidents were not recorded appropriately with contradicting information about how the incident occurred. We spoke with registered manager, who told us it was a recording issue with staff, however, when we spoke with people, we received a different account on how the incident occurred. We were not assured appropriate action and lessons were learnt following incidents as there had been no discussions about mitigating the risks in the future. Overall, we found that Sherborne Court Neurological Centre provided an open and supportive environment where people and their relatives could freely share their views. Staff clearly described how they would respond to incidents or accidents and who they would inform. One staff member told us, “We have morning handovers to keep us updated on any overnight changes. We complete care notes on handheld devices, and if we notice any changes or incidents, we report these verbally to the nurses.”

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. Prior to people moving into the service, information was gathered from relevant professionals and preadmission assessments were completed with people and/or their relatives. Assessments were conducted in person, usually by the registered manager, who ensured the service could meet the person’s needs.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately. Systems were in place to manage safeguarding incidents. However, we observed staff kept some people’s cigarettes and/or vapes, and this was not recorded in their care plans to show consent. There was no evidence Mental Capacity Assessments or Best Interest decisions had been complete to evidence steps taken to support people make informed decisions. Where people had a Deprivation of Liberty Safeguards (DoLS) in place, the management team monitored authorisations to ensure they were in date and relevant. Staff had received training in safeguarding people from abuse and understood their safeguarding responsibilities. A relative told us, “[Name] is safe here, I do not have to worry about his care as staff know what they’re doing.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Although records for people at risk of choking or those on a modified diet were completed, staff did not always follow them. We reviewed one record of a choking incident for one person whose diet records showed they had been given food which did not align with the recommended dietary requirements. This increased the risk of choking. We raised our concerns with the registered manager who assured us this would be looked into. We reviewed accidents and incidents and noted a record involving a person and the use of alcohol, during which staff had removed the individual’s alcohol, leading to a disagreement. There was no evidence of a positive risk assessment in place for this person, despite them having the capacity to make decisions about drinking alcohol.

The provider mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Most environmental risks had been assessed and mitigated such as electrical equipment and water safety. People had up to date personal emergency evacuation plans (PEEPS) to guide staff during an emergency on how much support people would require to evacuate the building. We saw a fire extinguisher off the wall in the lounge area, posing a risk to people. We found 2 main bathrooms on the ground floor were used to store moving and handling equipment and wheelchairs, making them inaccessible. Moreover, one bathroom had a fire door wedged open. We raised this with the management team who informed us of ongoing improvement plans to maintain and upgrade the service.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. We saw people interacting with staff in a relaxed and friendly way. Pre-employment checks were completed prior to staff starting work. There was a training matrix in place to oversee which courses staff had completed and identify areas of additional learning requirements. However, not all staff had up-to-date training. Following our assessment, the provider confirmed that expired training had been scheduled, and we also saw evidence of planned training displayed on the staff notice board.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Some surfaces were permeable, which made them difficult for housekeeping staff to fully sanitise. This included areas where paint had flaked off the wall. The provider had a refurbishment programme in place to address these concerns. Staff had completed infection prevention and control training, however, we observed bins contained clinical waste and used personal protective equipment (PPE), even though clinical waste bins were available around the service. This was raised with the provider, who promptly procured appropriate bins before the conclusion of our assessment. The provider had an action plan in place to address infection prevention and control (IPC) concerns previously identified by the local authority quality team and had addressed some of the concerns raised.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were not always managed safely. We found instances where some medicines, such as topical creams, were not always stored safely. We found some thickening agents prescribed for a person who had passed away were still being used for other people using the service. When we reviewed some records, we found one person was storing medication in their bedroom. This meant staff were not consistently observing the person taking their medication, despite being responsible for providing medication support. This put the person at risk of overdosing. We raised some of these issues with the management team who promptly rectified them.