CQC report explained · a nursing home
What the CQC found at Somerhill Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicine records did not always give staff enough guidance, including guidance for oxygen and medicines given when needed. Inspectors also found concerns about staffing and some risk assessments, although people were safeguarded and received medicines as prescribed.
- Effective?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward.
- Caring?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward, although inspectors observed staff respecting choices and people described staff as kind and caring.
- Responsive?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- The home had an open culture and responded to complaints, but inspectors were not assured that feedback about staffing and other problems was acted on effectively.
What inspectors found, December 2023
Somerhill Care Home is rated Requires Improvement; inspectors found kind care, but concerns about staffing, medicines and effective management.
Inspectors made an unannounced focused visit on 16 October 2023. They spoke with people living in the home, relatives and staff. They also observed care and checked care, medicines, staff and management records.
The home was rated Requires Improvement overall. Safe was rated Requires Improvement because medicines guidance was incomplete, some risks were not clearly recorded, and staffing did not always appear to meet people's needs. Well-led was also rated Requires Improvement because action taken after concerns was not always effective.
People generally described staff as kind and caring. Inspectors saw staff respecting choices and supporting people to make decisions. The home was clean, people received medicines as prescribed, and safeguarding concerns were dealt with appropriately.
This was a focused inspection of Safe and Well-led only. The ratings for the other three areas were carried forward from the previous inspection. The previous overall rating was Good, published on 5 August 2021.
Kind and respectful staff
People spoke positively about staff. Inspectors saw staff offering choices, asking for consent and respecting people's decisions.
“The staff couldn't be nicer. I like all of them, they are all kind and caring” from the report
Safeguarding
Inspectors found that people were protected from abuse and avoidable harm. Staff had safeguarding training and knew what to do if they had concerns.
“People were safeguarded from abuse and avoidable harm.” from the report
Open feedback culture
People, relatives and staff could share feedback in meetings and through complaints. Inspectors found that complaints were responded to appropriately.
“There was an open and transparent culture within the service.” from the report
Clean and maintained home
The home was clean. Cleaning, infection control and safety checks took place regularly, and equipment was serviced.
“We saw infection control audits took place on a regular basis and issues were addressed.” from the report
Medicines guidance
seriousSome care plans and medicine records did not contain enough detail for staff to give medicines safely. Protocols for medicines given when needed were missing for some people, and some handwritten records were not double signed.
“People did not always have medicine when required (PRN) protocols in place.” from the report
Staffing and personal care
needs fixingSome people and staff said there were not always enough staff. Inspectors were not assured that staffing levels were based fully on people's needs and feedback.
“We were not assured the provider had taken a person-centred approach in relation to staffing levels within the service.” from the report
Dignity and access to showers
needs fixingA washing machine had been out of service for at least a month. This affected access to towels and meant people could not always have a shower when they wanted.
“People could not always have a shower when they liked due to not having towels available.” from the report
Management follow-through
needs fixingThe home carried out audits and made some changes, but inspectors found that action did not always solve the problems quickly or effectively.
“We found audits were taken regularly and actions taken as a result, however, we found action was not always effective.” from the report
- 01What has changed to make sure staffing levels meet people's needs, including help with personal care when they want it?
- 02How are you making sure every person has clear instructions for medicines given when needed?
- 03How do you check that oxygen guidance and other medicine information is transferred into care plans and medicine records?
- 04What action has been taken since the inspection to make sure audits lead to problems being fixed promptly?
- 05How do you use feedback from people and relatives when deciding whether staffing levels are enough?
This was an unannounced focused inspection of Safe and Well-led only; the other three ratings were carried forward from the previous inspection. This explanation was written from the published report of 13 December 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2022
Inspected but not rated; inspectors found the home clean, visiting unrestricted and no evidence of unlawful restrictive practice.
This was an unannounced, targeted inspection on 11 October 2022. Inspectors were checking specific concerns about cleanliness and restrictive practice, rather than carrying out a full inspection.
The home was clean and smelled fresh. Inspectors found suitable infection control arrangements, including correct use of protective equipment, handwashing facilities and supplies. They found no evidence to support the concern about cleanliness.
Inspectors reviewed one person's care records and found guidance to help staff respond to distress. They found mental capacity assessments and best-interest decisions, and no evidence of unlawful restrictive practice. People could receive visits from family and friends without restrictions.
The service was not given a new rating. The previous rating was Good, but this targeted inspection did not assess the whole service or the whole Safe question.
Clean environment
Inspectors found the home clean and fresh, with no evidence supporting the concern they had received about cleanliness.
“The home was clean and smelt fresh, we did not find any evidence to substantiate that concern.” from the report
Infection control
Staff used protective equipment correctly and supplies were available. Inspectors were assured about the home's arrangements for preventing and managing infection.
“Staff were observed wearing the correct personal protective equipment (PPE) and there was stock available.” from the report
Support with distress
The care records reviewed included person-centred guidance for supporting someone when they became distressed.
“One person we reviewed had guidance in place for staff to use when supporting them.” from the report
Inspectors raised no specific concerns in this report.
- 01When will the next comprehensive inspection assess the whole Safe question and the other four key questions?
- 02How do you record mental capacity assessments and best-interest decisions for people who may lack capacity?
- 03What guidance do staff follow when a person becomes distressed, and how is this guidance kept up to date?
- 04How do you check that protective equipment remains available and is used safely?
- 05How do you respond if there is an infection outbreak or a new concern about cleanliness?
This was a targeted inspection of specific concerns about cleanliness, restrictive practice and infection control; it did not assess the whole Safe question or the other key questions, so the previous Good rating was not changed. This explanation was written from the published report of 3 November 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Somerhill Care Home
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2022Inspected but not ratedSafe: Inspected but not rated
- August 2021Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- April 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- June 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2017Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2022
Registered with the Care Quality Commission on 30 June 2022.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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