CQC report explained · a nursing home
What the CQC found at Sovereign House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2023
Requires Improvement; inspectors found people were supported by enough staff, but risks, medicines, cleanliness and management checks were not always safe or reliable.
This was an unannounced focused inspection on 16 November and 2 December 2022. Inspectors spoke with people, relatives and staff, and checked care records, medicines records, staff files and management documents.
The home was not always safe. Some people did not have complete risk assessments or care plans. Inspectors also found unsafe medicines storage, missing guidance for some medicines, and areas that were not clean or easy to clean. Staff had enough numbers to support people, but some needed more training to support people living with dementia or communication difficulties.
The home was not always well-led. Checks by managers did not identify all risks, and some nurse competency checks had expired. The provider remained in breach of regulations 12 and 17. The overall rating stayed at Requires Improvement, as did the Safe and Well-led ratings.
Enough staff
Inspectors found there were enough staff to meet people's needs. Recruitment checks were completed before staff started work.
“We found there were enough staff to support people at the home.” from the report
Safeguarding
People were protected from abuse, and staff knew how to report concerns. The home made safeguarding referrals when needed.
“People were protected from the risk of abuse.” from the report
Working with health professionals
The home worked with health and social care professionals and helped people access specialist teams for complex needs.
“People were supported to access specialist health teams when further advice and treatment was required for complex needs.” from the report
Incomplete risk information
seriousSome people admitted for short-term assessment and rehabilitation did not have risk assessments for catheter care, continence care or skin checks. This meant staff did not always have enough written guidance to reduce risks.
“This meant staff did not have enough information and guidance on how to reduce risks to people's health and safety or how to respond if further attention was required.” from the report
Medicines management
seriousSome medicines and nutritional feeds were not stored safely, and two people did not have written guidance for medicines or treatments given when needed.
“Medicines were not always stored safely.” from the report
Cleaning and infection control
needs fixingSome surfaces were damaged and dirty, and inspectors found a commode and chair that had not been cleaned effectively. A small number of staff also did not use face masks correctly on the first visit.
“Where cleaning had taken place, this was not always completed effectively and some areas remained unclean.” from the report
Management oversight and training
seriousManagement checks did not identify all environmental risks. Competency checks for six nurses had expired, and inspectors found no evidence of PEG feed training in six nurse files.
“Oversight of the clinical competencies of nurses at the home was not always effective.” from the report
- 01How have you completed and checked risk assessments for catheter care, continence care and skin integrity?
- 02How are medicines, thickener and nutritional feeds stored safely, and how are required temperatures recorded?
- 03What checks now confirm that cleaning is completed properly in communal areas and after equipment is used?
- 04How do you monitor nurse competency checks and training for catheterisation, diabetes, epilepsy and PEG feeds?
- 05What dementia and communication training have staff completed, and how do you check that it improves care?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 10 January 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, January 2022
Sovereign House is rated Requires Improvement; inspectors found risks with repositioning, medicines, infection control and management oversight.
This was an unannounced focused inspection on 24 November 2021. Inspectors looked only at Safe and Well-led because the inspection followed concerns about staffing, records and complaints. They spoke with people, relatives and staff, and reviewed care, medicines, staffing and management records.
Inspectors found that three people at risk of pressure ulcers did not have repositioning recorded between 6pm and 10pm. Medicines were not always stored or recorded safely. Infection control problems included insufficient clinical waste bins, a bin that did not close properly, delayed removal of soiled linen and missing toilet tiles.
The home had enough staff overall, and people and relatives generally said people felt safe and cared for. However, checks by managers had not found several of the problems. The overall rating stayed at Requires Improvement, the same as the previous rating published in October 2019.
People felt safe
People and relatives generally said people were safe and staff cared about them.
“There is always someone on duty who knows what they are doing.” from the report
Staffing and recruitment
Inspectors found enough staff overall, and recruitment checks and induction were in place.
“The rotas showed that the number of staff on duty was in line with the tool the registered manager used to form the rota.” from the report
Learning from incidents
Accidents and incidents were reviewed for patterns, and changes such as room sensors had been introduced after falls.
“These were analysed for themes such as falls and used to make improvements such as sensors in the rooms of people on the rehabilitation pathway” from the report
Links with professionals
Staff worked with GPs and district nurses when people needed further help or support.
“Records showed staff liaised with a range of professionals such as the GP's and district nurses where needed” from the report
Repositioning records
seriousThree people's records did not show repositioning between 6pm and 10pm, so inspectors could not confirm that care had happened as planned. This increased the risk of pressure ulcers.
“records for three people showed this was not recorded between 6pm and 10pm. This meant it was not possible to know if repositioning had taken place” from the report
Medicine safety
seriousOpened creams were accessible in communal bathrooms, a controlled drugs record contained an error, and medicines were stored in an unlocked cupboard under a sink. The manager ordered a lockable cupboard during the inspection.
“Staff stored opened creams on high shelves in the communal bathrooms leaving them accessible to people they were not prescribed for.” from the report
Infection control
needs fixingThere were too few clinical waste bins, one bin did not close properly, soiled linen had not been moved promptly and missing tiles made cleaning difficult. The manager took immediate steps, but existing audits had not found these issues.
“We found each floor of the home only had one clinical waste bin stored in the sluice rooms which was not adequate for the number of people in the home.” from the report
Weak management checks
seriousThe home's checks did not reliably find gaps in care records, medicine management or infection control. This led to a breach of the good governance regulation.
“These did not always identify gaps in recording or when care had not been provided in the way identified in care plans.” from the report
Communication with relatives
minorSome relatives said the management team did not respond quickly enough to concerns or tell them when things went wrong. Laundry problems were also reported.
“Four relatives said communication with the home could be improved and two relatives said they didn't find the management team responded quickly enough” from the report
- 01How do you now make sure people who need repositioning are turned at the times set out in their care plans, including during the evening?
- 02Where are medicines and opened creams stored, and how often are storage and records checked?
- 03What has been done to fix the clinical waste, soiled linen and missing tile problems, and how is this now audited?
- 04What actions were included in the improvement plan after the two breaches, and what progress has been made?
- 05How will relatives be told promptly when something goes wrong or when they raise a concern?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 6 January 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 Sovereign House
4 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- January 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- August 2018Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2017
Registered with the Care Quality Commission on 9 November 2017.
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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