CQC report explained · a nursing home
What the CQC found at Summerdale Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Rated Requires Improvement; medicines were not always managed safely, although the home had improved and was no longer in Special Measures.
This was an unannounced follow-up inspection. Inspectors visited on 23 and 27 February 2023 and spoke with people, relatives, staff and managers. They reviewed care records, medicine records, staff files and management checks.
The home had made several improvements since its previous inadequate rating. The building was cleaner and being refurbished. Inspectors found good care in the effective, caring and responsive areas. People and relatives said their experience had improved.
However, medicines were still not managed safely. Some medicine risks were missing from care plans, fridge temperatures were not checked correctly, and a nurse was interrupted during a medicine round. These problems meant the home remained in breach of Regulation 12.
The overall rating is Requires Improvement. Safe and well-led were rated Requires Improvement, while effective, caring and responsive were rated Good. The home had been in Special Measures since October 2022, but was no longer in Special Measures after this inspection.
Kind and respectful care
People and relatives described staff as kind and respectful. Inspectors saw staff protecting privacy and dignity during personal care.
“We observed staff knocking on people's doors and closing the door when supporting a person with personal care.” from the report
Personalised support
Care plans included people's life histories, likes and preferences. Staff knew people well and involved people and relatives in care planning.
“Care records reviewed were person centred, the home had introduced a booklet named "My choice” from the report
Activities and choice
People were offered a wide variety of activities, including entertainment, celebrations and community links. The home also asked people what activities they wanted.
“The provider involved people in activities relevant to them, considering their background and culture.” from the report
Improved environment
The home was clean and undergoing refurbishment. Bedrooms had been redecorated and people and relatives noticed the changes.
“The home was nicely decorated, well maintained and clean.” from the report
Improved leadership
The management team had introduced more meetings, checks and audits. People, relatives and staff spoke positively about the manager and the changes.
“The management team had made significant improvements to the home.” from the report
Medicine risks were not fully assessed
seriousSome care plans did not explain the risks of prescribed medicines, including the risk of bleeding from oral anticoagulants. This was a breach and could put people at risk of harm.
“Systems had not been established to assess, monitor and mitigate risks in the proper and safe management of medicines; This placed people at risk of harm.” from the report
Medicine storage checks
seriousMedicine fridge temperatures were not monitored correctly. Medicine audits had not found this problem.
“Medicines were stored securely. Although fridge temperature was not effectively monitored.” from the report
Interruptions during medicine rounds
needs fixingA nurse was interrupted frequently while giving medicines and did not wear the available Do Not Disturb apron.
“There were frequent interruptions from other staff. Although there was a 'Do not disturb' apron available, this was not worn by the nurse.” from the report
Recruitment records
minorSome staff files were incomplete. Two files did not contain interview notes, and inspectors made a recommendation about recruitment practice.
“Some of the recruitment records we reviewed had some gaps in information.” from the report
Some delays with meals
needs fixingPeople in their rooms were not always supported to eat promptly on the inspection day because a staff absence could not be covered. Some people and relatives also raised concerns about the food.
“People who were in their rooms were not always supported to eat their meals in a timely manner.” from the report
- 01What specific changes have you made to assess and record medicine risks, including bleeding risks for people taking oral anticoagulants?
- 02How do you now check medicine fridge temperatures, and who reviews the records?
- 03How will you prevent interruptions during medicine rounds, and is the Do Not Disturb apron always used?
- 04How are you checking that staff recruitment files are complete, including interview notes?
- 05How do you make sure people in their rooms receive meals without avoidable delays when staff are off sick?
This was an unannounced follow-up inspection covering all five key questions and infection prevention and control, after the previous inadequate inspection and action plan. This explanation was written from the published report of 25 April 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, October 2022
Rated Inadequate and placed in special measures; inspectors found widespread safety risks, poor oversight and care that did not always meet people's needs.
This was an unannounced inspection. Inspectors visited on 31 August and 2 September 2022, with inspection activity continuing until 16 September. They spoke with people, relatives and staff, observed care, and checked care records, medicines, training, rotas and management records.
The inspectors found widespread safety concerns. Medicines were not always given as prescribed, risks were not properly assessed, staffing was not always sufficient, and the home was unclean and poorly maintained. Infection control was poor, and some safeguarding concerns had not been reported.
Care records were often incomplete or out of date. People's dementia care, communication needs, cultural preferences, activities, nutrition and personal care were not always properly planned. Inspectors also found that people's dignity, privacy, independence and involvement in decisions were not always respected.
The home was rated Inadequate overall, with Safe and Well-led also rated Inadequate. Effective, Caring and Responsive were rated Requires Improvement. The home was placed in special measures, meaning CQC will keep it under review and normally re-inspect within six months if registration is not being cancelled.
Access to healthcare
The home worked with other agencies and people could access healthcare services when needed. A GP regularly visited the home.
“The provider worked in partnership with other agencies to ensure people got access to healthcare services.” from the report
Mental capacity safeguards
Inspectors found that capacity assessments and best-interest meetings were recorded. Staff sought consent and appropriate legal authorisations were in place where needed.
“We found the service was working within the principles of the MCA and appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Food choices
People were offered a choice of meals, and staff showed them the available food so they could choose at the time.
“People were given a choice of meals, and staff physically showed the meals on offer to people so that they can make a choice at the time.” from the report
Recruitment checks
Recruitment records showed that required checks had been completed before staff worked unsupervised.
“Staff recruitment records showed relevant checks had been completed before staff began working unsupervised at the service.” from the report
Complaints process
The home had a complaints process, and inspectors found that complaints were logged and dealt with according to the provider's procedure.
“The registered manager maintained a log of any complaints made about the service, which had been addressed in line with the provider's complaints procedure.” from the report
Medicines were not consistently safe
seriousOne person had not received a prescribed medicine for eight days. Records and guidance for some medicines were missing, and audits did not identify the problems.
“Medicines were not always safely managed. People did not always receive their medicines as prescribed which meant they were at risk of harm.” from the report
Risks were not properly managed
seriousImportant risks, including falls, choking, diabetes, mobility, breathing difficulties and behaviour, were not always assessed or covered by clear staff guidance.
“People were not protected from risks to their health and wellbeing. Risks to people had not been adequately assessed, identified and managed, which placed them at risk of avoidable harm.” from the report
Staffing delays
seriousStaff were not always deployed where needed. People were left unsupervised in some lounges and sometimes waited a long time for support.
“We saw that staff were not deployed to meet people's need effectively and in a timely manner.” from the report
Weak staff training and management checks
needs fixingTraining records showed very low completion levels in several important subjects. Quality audits were missing or ineffective, so serious problems were not identified promptly.
“The provider had failed to carry out regular audits to identify issues.” from the report
- 01What evidence can you show that all prescribed medicines are now administered and recorded correctly?
- 02How have you reassessed each person's risks, including falls, choking, diabetes, mobility and breathing difficulties?
- 03What has been done to clean and repair the home, including the fire doors, handrail, carpets and damaged chair coverings?
- 04How do you make sure there are enough staff in each area and that people are not left waiting for personal care, meals or activities?
- 05How are residents and relatives now involved in updating care plans and recording cultural, communication, dementia and end of life preferences?
This was an unannounced inspection covering all five key questions, the premises and the care provided; inspection activity started on 31 August and ended on 16 September 2022. This explanation was written from the published report of 29 October 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 Summerdale Court Care Home
9 rated inspections over 7 years: the service has improved, from Inadequate to Requires improvement.
- April 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2022InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2021Inspected but not ratedSafe: Inspected but not rated
- October 2020Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- March 2020Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2019Inadequatedown from Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: InadequateResponsive: Requires improvementWell-led: Inadequate
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- February 2016InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- March 2022
Registered with the Care Quality Commission on 29 March 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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