CQC report explained · a residential care home
What the CQC found at Sotwell Hill House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2023
Sotwell Hill House was rated Requires Improvement; inspectors found kind care but gaps in risk records and management oversight.
This was an unannounced, focused inspection on 24 May 2023. One inspector and an Expert by Experience spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was not always safe. Some risks were not properly assessed or recorded, injury records lacked important details, and repositioning records showed gaps of up to six hours. There was also conflicting information about choking risks and safety checks.
Inspectors found kind and caring staff, safe recruitment, medicines usually given as prescribed, and improved management of legionella risks. However, audits had not found several problems, so the home remained in breach of Regulation 17 on good governance and received a Warning Notice.
The overall rating was Requires Improvement. Safe and Well-led were both rated Requires Improvement. This was a focused inspection, so the other three question ratings were carried forward from the previous inspection.
Kind staff
Inspectors saw staff treating people kindly and relatives spoke positively about the staff team.
“During the inspection we observed staff responding to people in a kind, considerate manner.” from the report
Medicines
Medicines were stored, given, recorded and disposed of safely. Staff were trained, although some protocols for medicines given when needed were missing.
“Medicines were managed safely. This included the storage, administration, recording and disposal of medicines.” from the report
Legionella improvements
The home had acted on the previous recommendation about legionella by providing training and obtaining an external risk assessment.
“At this inspection the provider had completed legionella training and had a risk assessment completed by an external company to identify and mitigate any risks.” from the report
Communication
People and relatives were kept informed about changes and incidents. Staff also received information through meetings, supervision and handovers.
“Relatives and people were kept up to date with any changes.” from the report
Incomplete risk assessments
seriousNot all risks had been assessed or linked to clear instructions for staff. There was conflicting information about thickener for fluids and how often one person should be checked.
“Not all risks had been assessed and mitigating strategies recorded.” from the report
Gaps in repositioning records
seriousOne person who needed repositioning every two hours did not consistently receive it. Records showed gaps of six hours, increasing the risk of pressure damage.
“We found records of support with repositioning that evidenced gaps of 6 hours.” from the report
Poor management oversight
seriousAudits repeatedly failed to identify missing or conflicting safety information. The provider remained in breach of Regulation 17.
“The provider failed to ensure adequate systems and processes were in place to assess, monitor and improve the quality and safety of the care provided.” from the report
Missing medicines protocols
needs fixingSome protocols for as-required medicines did not explain how they should be used for the prescribed reason. The manager put protocols in place immediately after the inspection.
“However, not all 'as required' (PRN) medicines had detailed protocols in place to ensure, they were being used in line with the prescribed reason.” from the report
- 01How have you checked that the new risk assessments contain clear instructions for staff, including for people who cannot use a call bell?
- 02What checks now make sure injuries are fully recorded, investigated and followed up until they heal?
- 03How do you ensure people receive repositioning at the required intervals, and how do managers review these records?
- 04Have all as-required medicines now got clear protocols explaining when and why they should be given?
- 05What evidence can you show that the Warning Notice and the Regulation 17 breach have been addressed?
This was an unannounced focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 23 August 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, March 2022
Rated Requires Improvement; inspectors found kind care and safe medicines, but weaknesses in falls management, staffing at night and quality checks.
This was an unannounced inspection on 11 and 19 January 2022. Inspectors spoke with five people, 10 staff, relatives and a healthcare professional. They reviewed care records, medicines records, staffing and quality checks.
The home was caring and people said they felt safe. Medicines were given as prescribed, staff were trained, recruitment checks were carried out, and infection control arrangements were suitable. However, falls risks were not always reviewed after incidents, care records sometimes conflicted, and night staffing did not fully reflect the building layout or evacuation needs.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used when calculating the overall rating. The provider breached Regulation 17 on good governance and was asked to send an action plan.
Medicines
People received their medicines as prescribed. Records of administration were accurate and staff competence was checked.
“People received their medicines as prescribed and the service had safe medicine storage systems in place.” from the report
Staff suitability and training
The home carried out recruitment checks and gave staff regular training, supervision and observations of their work.
“The provider followed safe recruitment practices and ensured people were protected against the employment of unsuitable staff.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for infection prevention, testing, protective equipment and visits during the pandemic.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Kind and familiar care
People said they felt safe and staff knew them well. Relatives gave very positive feedback about how the home was run.
“People living at Sotwell Hill House told us they felt safe receiving care from compassionate staff who new them well.” from the report
Night staffing and evacuation
seriousThe inspection found that night staffing and the evacuation plan did not fully reflect the home's layout or the possibility of needing to evacuate people safely.
“The fire risk assessment and evacuation plan did not take into account the staffing levels at night and the layout of the building.” from the report
Legionella controls
needs fixingThe home had part of a system for managing legionella risk, but it did not have a risk assessment, management plan or additional controls recommended in the relevant code of practice.
“They did not have a risk assessment or management plan to measure against this risk.” from the report
Quality checks
seriousThe home's audits had not identified the problems inspectors found in care records and risk assessments. This was the subject of the legal breach.
“The provider's quality assurance systems were not always effective and not used to drive improvement.” from the report
- 01What changes have you made to review falls assessments and care plans immediately after a fall?
- 02How do you now identify and act on patterns in falls, especially unwitnessed falls during the night?
- 03What are the current night staffing levels, and how would people be evacuated safely from all parts of the building?
- 04What legionella risk assessment, management plan and water safety checks are now in place?
- 05How often are care records and risk assessments audited, and how do you check that identified problems have been fixed?
This was a focused inspection of Safe and Well-led, prompted partly by concerns about accident and incident risks; the other ratings carried over from the previous inspection. This explanation was written from the published report of 30 March 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 Sotwell Hill House
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2019Goodstayed GoodSafe: Requires improvementWell-led: Good
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 January 2011.
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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