CQC report explained · a residential care home
What the CQC found at Sutherland Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were protected from abuse and medicines were managed safely. However, face masks were not always worn correctly and some risk assessments had not been signed and dated.
- Effective?
- Requires improvement
- Training, consent processes and DoLS management had improved. Some people's dietary needs were not consistently met, and some mental capacity records were not signed and dated.
- Caring?
- Requires improvement
- This question was not covered by this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Requires improvement
- New person-centred plans, communication plans and activity plans had been introduced. However, information was not always consistent, communication pictures were not used routinely, and activity plans needed further development.
- Well-led?
- Requires improvement
- A new management and quality team had introduced improvement plans and governance systems. These systems were new, so inspectors could not yet see whether they would consistently bring about change.
What inspectors found, May 2022
Rated Requires Improvement; improvements ended special measures, but inspectors still found gaps in safety, nutrition, records and person-centred support.
This was an unannounced focused inspection on 16 and 17 March 2022. Two inspectors observed care, spoke with relatives and staff, and checked medicines, care records, training and management records.
The home had improved since its previous Inadequate rating in August 2021. Staff understood safeguarding, medicines were managed safely, staffing and training had improved, and new care plans were helping people make choices and develop independence.
Important work was still unfinished. Some risk and mental capacity records were not signed and dated, staff did not always wear face masks correctly, and some people's diets and communication support did not consistently meet their needs.
The overall rating changed from Inadequate to Requires Improvement. The home was no longer in breach of regulations or in special measures, but CQC will continue to monitor it.
Safeguarding
Staff understood how to protect people from abuse and knew what to do if they thought someone was at risk.
“People were safe from abuse. Staff understood how to protect people from abuse and knew what to do if they thought someone was at risk.” from the report
Medicines
People received their medicines at the right time. Records also described how each person preferred to receive them, and staff followed those preferences.
“People received the correct medicines at the right time. People's medicines were regularly reviewed to monitor the effects of medicines on their health and wellbeing.” from the report
Choice and independence
New care plans and personal documents helped staff understand people's abilities, goals, communication and preferences. Inspectors saw people choosing where to spend their time.
“People appeared relaxed and comfortable, we saw people choosing where to spend their time and engaging in activities they enjoyed or found comforting.” from the report
Improvement work
The home had acted on the previous inspection. Staff training, consent processes, DoLS records and quality systems had all improved.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Dietary support
needs fixingRecords did not always show that a person with particular dietary needs was receiving suitable food. One person's suggested meal included food they did not enjoy.
“Records for a person with a person with particular dietary needs due to health conditions did not always demonstrate that the person was provided with a diet suitable to their needs and preferences.” from the report
Infection control
needs fixingStaff were not always wearing face masks correctly. Inspectors were only somewhat assured that visitors were protected from catching or spreading infections.
“Staff were not always wearing face masks correctly.” from the report
Incomplete records
needs fixingSome risk assessments and mental capacity records had not been signed and dated. This makes it harder to show that decisions and risks have been properly checked.
“Mental capacity assessments and best interest decisions had been completed. However, we found these had not always being signed and dated as required by the form.” from the report
Communication support
needs fixingPictures had been introduced to help people understand information, but staff did not use them routinely. More personalised pictures were also needed in people's documents.
“Although use of pictures as a means of accessible information had increased, for example, pictures were available to help people choose activities and meals and pictorial menus had also been introduced, we did not see staff use these routinely.” from the report
Outdoor access
needs fixingThe home needed more work to make its outdoor space safe and comfortable for people to use.
“Further work was needed to make sure people could access and enjoy the outdoor space safely and comfortably.” from the report
- 01How will you make sure each person's dietary needs and food preferences are followed every day?
- 02What checks now ensure risk assessments and mental capacity records are signed and dated?
- 03How do staff use each person's communication pictures and other non-verbal communication guidance in daily care?
- 04What has been done to make the outdoor space safe and comfortable to use?
- 05How will you measure whether the new quality and improvement systems are bringing about lasting changes?
This was a focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected and the previous rating was used in calculating the overall rating. This explanation was written from the published report of 26 May 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.
What inspectors found, February 2022
Inspected but not rated; inspectors were assured about infection prevention and control, including PPE, cleaning and visits.
This was a targeted inspection focused on infection prevention and control during the COVID-19 pandemic. Inspectors also asked about staffing pressures and whether these affected care. The visit was announced with 24 hours' notice.
Inspectors found the home clean and uncluttered. They were assured that the home used PPE safely, supported visiting, managed testing and admissions safely, and had suitable infection prevention policies.
The home was inspected but not rated. This means the report does not give an overall quality rating or a full rating for the five areas of care.
Clean and uncluttered home
The premises were clean and arranged so that cleaning could take place effectively.
“The premises were clean. All areas of the home were uncluttered so cleaning could take place effectively” from the report
PPE and safety guidance
Staff were seen using appropriate protective equipment, with signs and instructions supporting safe infection prevention.
“Staff were observed wearing appropriate PPE. There was signage and instructions promoting safe infection prevention practices.” from the report
Safe laundry processes
Inspectors found that laundry was managed through effective safety processes.
“The service had effective processes in place so laundry was managed safely.” from the report
Support for visits
Inspectors were assured that visits were being facilitated in line with the guidance in force at the time.
“We were assured the provider was facilitating visits for people living in the home in accordance with the current guidance.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing staffing pressures, and have they affected people's care or routines?
- 02How do you currently support visits and keep relatives informed if infection restrictions change?
- 03How do you test people and staff when testing is difficult or a person cannot take part?
- 04How do you prevent and manage infection outbreaks, and when was the infection prevention policy last reviewed?
- 05How do you check that visiting professionals meet the current COVID-19 vaccination or exemption requirements?
This was a targeted inspection of infection prevention and control, with questions about staffing pressures; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 11 February 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 Sutherland Court
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- May 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- August 2021Inadequatedown from Requires improvementSafe: Requires improvementEffective: InadequateResponsive: InadequateWell-led: Inadequate
- March 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 15 March 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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