Sherborne Court Neurological Centre

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 management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 57 (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, 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. People, relatives, and staff were actively involved in discussions and decisions about how Sherbourne Court Neurological Centre was run. Everyone we spoke with said their views were welcomed and valued by the provider. Individuals could leave feedback when signing in or out of the building, and if the rating fell below ‘good’, it triggered a management review to investigate any concerns.

Not all leaders understood the context in which the provider delivered care, treatment and support. The registered manager was open and transparent throughout the assessment and demonstrated a willingness to make improvements where concerns were identified. However, some members of the management team were not aware of the service user guide provided to people who were new to the service. Although this information was shared with us after the assessment, the lack of management awareness meant we could not be assured that people consistently received this information to support them during their move into the service. Despite this, people, relatives, staff, and professionals provided positive feedback about the management team. One person said, “I enjoy living here, there is always staff around to help me with whatever I need, we have a bit of banter with staff.”

Staff did not always feel confident they could speak up or their concerns would be heard. While leaders generally acted with openness and honesty and encouraged staff to raise concerns in meetings or confidentially, some staff felt parts of the management team did not consistently respond to concerns about the unequal distribution of workload. Several staff reported fear of negative consequences, including job security, if they raised issues. These concerns were discussed with the registered manager, who advised the provider was aware of them and was arranging external support to work with the team and help improve staff cohesion.

The provider valued diversity within the workforce; however, they did not always promote an inclusive and fair culture that improved equality and equity for staff, particularly those with protected characteristics. Feedback from staff about the management team was mixed. Some staff reported feeling unsupported and said they did not raise concerns because previous issues had not been acted upon. In contrast, one staff member spoke positively about working at Sherbourne Court Neurological Centre, stating, “The managers are very approachable, they listen to what you say, and they are always available to us.”

The provider had clear roles, responsibilities, and systems of accountability; however, they did not always act on the best available risk information or share it appropriately. The provider had systems in place to support auditing, including daily flash meetings and multidisciplinary meetings; however, some auditing processes were underutilised. For example, the provider supported people who displayed distressed behaviours to communicate unmet needs, and behaviour charts were available to help identify triggers for these behaviours. However, these charts were completed for some people but not consistently for all. In addition, some members of the management team were not aware of the use of behavioural charts for people who presented with distressed behaviours which meant there were missed opportunities for analysis.

Audits undertaken were not always effective in identifying certain concerns found during the assessment, including issues related to infection prevention and control and the analysis of accidents and incidents.

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. There was evidence of joint working with professionals, and people were supported to access health services when needed. Referrals were made to relevant healthcare professionals; however, outcomes were not always clearly recorded in people’s care documentation. People were supported to access the local town and nearby amenities, as well as visit surrounding areas. Some individuals attended the ‘Gentlemen’s Club’, which they told us they enjoyed.

Although the provider promoted continuous learning and improvement across the organisation and local system, they did not always encourage creative approaches to ensure equality of experience, outcomes, and quality of life for people. The management team had oversight of accidents and incidents and held daily meetings with staff; however, it was not always clear whether learning from incidents was consistently applied. Records required strengthening to clearly demonstrate continuous learning. In addition, some concerns identified during this assessment had not been detected through the provider’s audit systems. Staff had access to training and opportunities to support innovation in their roles. The management team demonstrated a commitment to learning and improvement and worked to embed this across the service.