Sherwood

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.

This is the first assessment for this service under this provider. This key question has been rated Outstanding. This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This service scored 88 (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 proactive and positive culture of safety, based on openness and honesty. Risks to people were identified, assessed and regularly reviewed. Positive behaviour support plans provided staff with clear guidance on how to respond to behaviours of concern in a personalised and proactive way. This contributed to a reduction in incidents and improved wellbeing for people.

People were encouraged to understand how specific actions they took may place them at risk of harm. Care plans and risk assessments showed people had been involved in discussing risks. For example, people had sexual safety, online safety and community safety plans in place. These detailed actions taken to mitigate and manage known risks for people.

External professionals who worked with the service gave positive feedback about the approach of the service. One professional told us, “The service takes a proactive approach to identifying emerging concerns and works collaboratively with partner agencies to ensure appropriate support is in place.”

The management team ensured any learning from incidents which had occurred was shared with the staff team. Lessons were learnt to continually identify and embed good practice.

Regular staff meetings were held, to look at lessons learned and any improvements needed to existing practice. Daily handover meetings were held with the whole staff team, to ensure any updates or important information was promptly shared.

The provider always 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 consistency and continuity of care, including when people moved between different services.

Prior to moving into the service, a robust assessment was completed by the management team, to assess the suitability of the service and their ability to meet peoples identified needs. Staff worked hard to ensure people had a positive transition to their new home and understood the importance of allowing a settling in period. People were involved in reviews more regularly during this time, to ensure the service was consistently meeting their needs. One person said, “In the early days I didn’t think it would be good for me and thought I might be better at my previous place, but it feels now like here is the better place.”

The management team extensively reviewed and ‘matched’ proposed placements, to reduce any potential impact on existing residents. This ensured safe staffing levels and continuous support for people. People were supported by a highly skilled staff team who worked in partnership with external agencies, to ensure people received their support in the way they wished for. Each person had a detailed and personalised hospital passport. This included how people wished to be communicated with, what support needs they had, likes and dislikes and details of external partners involved with their care.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Safeguarding was an absolute priority at Sherwood. Staff were very clear of their responsibilities in ensuring people were kept safe from the potential risks of harm or abuse. Staff had all received enhanced training in safeguarding people living with learning disabilities and autistic people.

Incidents had been reported and investigated in a timely manner, with other appropriate agencies informed. Incidents and accidents were promptly investigated to ensure that remedial actions were taken, and any learning identified and shared with staff. Incident records clearly detailed the statutory organisations and people that were notified of each incident and any action that was taken to prevent reoccurrence. The management team fully understood their duty of candour, and we saw records showing relatives and advocates had been informed about incidents.

People all told us they felt safe living at Sherwood, and the staff team ensured they were fully supported in this. One person explained how they felt, “I feel the staff respond quickly when needed, when incidents have arisen.” Another person said, “I feel safe, its peaceful, having the staff around makes me feel safe.” One person explained how a previous incident with a peer had impacted them, they said, “I have felt unsafe before, but this person is no longer living here. The staff supported me through this and were very good. I feel much safer now things have settled.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the service followed best practice under the MCA, and people were not unnecessarily restricted by systems or processes.

The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

The provider worked closely with people to understand and manage risks in a way that promoted independence and choice. Risk assessments were highly personalised and co-produced with people, reflecting their preferences and aspirations alongside identified safety needs. Plans included detailed guidance on triggers, antecedents, and strategies for reducing distress, enabling staff to respond effectively and consistently. People were supported to take positive risks in pursuit of their goals, balancing safety and opportunity to maximise independence and quality of life.

This approach was embedded across the service, supported by regular reviews and management oversight to ensure plans remained current and effective. People told us they felt confident in the support provided and were actively involved in decisions about managing risks, including accessing community activities such as visiting family and friends, the cinema and bowling. One person said, “I can go out when I want to, I use the buses to go to Heanor, Ripley, Nottingham and Mansfield.” We saw this person’s community safety plan was detailed, personalised and was supportive without being restrictive. This demonstrated how people were empowered to safely access their local community and maintain meaningful relationships.

We saw examples where staffing levels had been reduced over time for individuals previously requiring a higher level of support, resulting in greater freedom and therapeutic engagement. These reflected significant achievements in peoples’ independence and demonstrated the provider’s commitment to help people reach their full potential. These changes were planned and monitored, demonstrating a commitment to enabling people to live fuller lives while maintaining safety. The use of easy-read guides and highly personalised emergency plans further supported people’s understanding and participation in risk management.

Some people had a history of showing physical signs of distress which could cause harm to themselves or others. Robust person-centred plans described how people’s potential distress may present, any antecedents and triggers and guided staff as to how to respond in the most effective way. People we spoke with had all been involved in co-producing their care plans and associated risk assessments. Each person had individualised risk management plans in place, relevant to any specific support needs they had. These were regularly reviewed by the staff team and informed by any changes to people's needs or incidents. Potential risks for people were anticipated both within the service, and outside in their community. Staff promptly responded to any changes and managed any potential distress in a safe and caring manner. This proactive and preventative approach enabled people to pursue their ambitions while reducing unnecessary restrictions on their lives. People had specific personalised plans in relation to their safety and support needs when out in the community. One person said, “I don’t use a mobile phone but would go to my relatives’ home, the church or the police if I felt unsafe.”

Easy read guides were available to support people in staying safe. Any triggers for anxiety or stress had been identified, and people had guidance about familiar transport routes, contact numbers and places of safety they could go to if they became anxious or unwell when out in the community.

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had fully invested in the service, and had recently purchased the building, which removed some of the previous barriers to maintenance.

Communal areas were well furnished and well maintained, with full consideration given to people who may require support with sensory needs. The environment had been thoughtfully designed to promote comfort, reduce anxiety and support people's individual sensory preferences and wellbeing. Each persons’ bedroom or flat was decorated to a high standard with people explaining how they were involved in choosing their own decor preferences. One person had extensive, organised collections displayed across their walls, which they proudly showed the inspection team. Each flat had a bathroom, kitchen area, lounge and bedroom, with plenty of space for staff to support people, without them feeling overwhelmed.

We were shown around the outside garden space, with outdoor furniture, a lawned area, flower beds, and a large smoking shelter for people to use. Signage and information displays around the whole service were in 'easy read format' which supported people to understand information easily. The service used ‘talking buttons’ to share important information with people who may find difficulty in reading. This innovative approach improved accessibility and enabled people to engage more independently with information that affected their daily lives.

People were happy to show us their personal spaces, and all people we spoke with felt happy with the quality of these. One person said, “The home is very well kept and looked after.”

The maintenance lead for the service was responsive and knew all people well. We saw the maintenance lead working with external contractors to complete refurbishment of the flats.

The documents in place for maintenance oversight were highly organised, with all required safety certificates in place. For example, regular checks on the water system, to ensure the risk of Legionella was minimised, and checks for equipment, such as the heating system. The maintenance lead showed a real understanding of supporting people living with mental health, people with a learning disability or autistic people, and ensured people were involved in decision making around their personal living spaces. A recent residents meeting had discussed whether people would like to assist the maintenance lead, with some of their daily tasks. The maintenance lead welcomed the idea of having a ‘resident assistant’ and was happy to support anyone who wished to get involved. This created opportunities for people to develop practical skills, increase confidence, gain a sense of achievement and take valued roles within their community.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

Staffing levels were set according to people's identified dependency needs to ensure that people were supported safely. On the day of our visit, we observed that people were supported by the right number of staff, as reflected in their care plans and risk assessments. This meant people could access the activities they wished, with the support of staff who fully understood their needs. People were positive about the support they received from the staff team. One person said, “I do feel the staff are well trained to provide my support.”

The management team showed excellence in their practice and understanding of people, and the staff team upheld these high standards. Staff were highly skilled and experienced in supporting people with their identified needs. We saw from the training matrix, that staff had completed training in further subjects which would support best practice. For example, all staff had received enhanced training in learning disabilities and autism. This allowed the staff team to have a clear understanding of the lived experiences of people with a learning disability or autistic people. Staff used this knowledge to adapt their approaches to ensure support was genuinely person-centred and responsive to individual communication styles, preferences and aspirations.

Staff worked proactively to continuously develop their specialist knowledge to meet people's individual needs, including complex health conditions. For example, staff had completed training in Autism and identity and the management of anxiety relating to medicines administered by injection.

Staff received a wide range of training and ongoing competency assessments, enabling them to provide skilled and confident support. People, relatives and partners consistently spoke positively about the knowledge and capability of staff. An external professional gave positive feedback about the staff team having a real understanding of people as individuals and ensuring this was shared with partners. They told us, “Staff facilitate and participate in meetings, reviews, and appointments when required.”

People were supported to be involved in the recruitment of staff. Ensuring staff had the qualities and approach that people wished for. This co-produced approach enabled people to directly influence who supported them and helped ensure new staff shared the service's values and commitment to person-centred care.

Recruitment processes were robust in ensuring staff were safe to work with people prior to commencing their role. Staff were required to provide their full employment history, suitable references and proof of identity. All staff had a current Disclosure and Barring Service (DBS) check. The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working with people who use care and support services. Where staff were registered professionals, we saw the related registers had been checked, for example, the Nursing and Midwifery Council register, (NMC).

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed the premises to be clean and well maintained on the day of our inspection. People’s personal spaces were well-kept, and people were encouraged to clean their individual living spaces. One person said, “The staff at the home help me clean my room regularly. I am happy with my room.” The high standards of the built environment allowed the service to be effectively cleaned to ensure the risk from infection was minimised.

Staff had access to personal protective equipment, such as gloves and aprons for carrying out any appropriate personal care or nursing tasks. We found all bathroom areas had access to soap, paper towels and hand gel.

The provider always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff always involved people in planning, including when changes happened.

We saw people were encouraged to understand their medicines and any impact these may have on their health and wellbeing. People gave positive feedback about the support they received with their medicines. One person said, “I am supported with medication. I do know what medication I take and the reasons for taking them. I have never had any problems with my medication.”

People received their medicines at the times they needed them and in a safe way. Medicines were stored securely in a temperature-controlled environment. Stock balance checks were taken daily to ensure medicine quantities were accurate. Medicines administration records (MAR) included a photograph of the person, demographic and healthcare professional details. All the MAR we viewed were up to date and accurately completed. Where people received ‘as required’, (PRN), medicines, detailed protocols were in place to ensure that staff were clear on when these medicines should be administered. Staff fully understood the importance of upholding the principles of Stopping Over Medication of People with a learning disability, autism or both, known as STOMP. Records showed regular reviews had been requested from the prescriber where staff felt the dosages could be amended. This led to better outcomes for people and supported their overall health and wellbeing. Drugs subject to extra control measures, were stored separately with accurate logs kept of their administration and balance checks. We found that staff were trained in the safe handling and administration of medications, and that competency checks were completed regularly by the management team, to ensure this was maintained.