CQC report explained · a residential care home
What the CQC found at Summerley Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found risks with medicines, staffing, training and care planning, with three regulations breached.
This was an unannounced focused inspection on 28 July 2022. Inspectors spoke with people, relatives, staff and health professionals. They observed care and reviewed care plans, medicine records, staff files and management records.
The home was not always safe or effective. Medicines records were incomplete and disordered. Some health risks were not properly assessed after hospital discharge. There were not always enough staff, and staff did not always have the training needed to support people living with dementia or distress.
The home’s checks and audits had not found or dealt with several of these problems. Inspectors found breaches of regulations about safe care and treatment, staffing and good governance. The overall rating remained Requires Improvement, as did Safe, Effective and Well-led.
Falls and nutrition risks
Falls risks were assessed and recorded in detail. People at risk of malnutrition or choking received measures such as fortified food, weight checks and referrals to health professionals.
“Falls risks were accurately assessed, monitored and recorded.” from the report
Health care links
People had access to routine and specialist health care. Records showed communication with health professionals and that their advice was put into practice.
“Records evidenced effective multi-disciplinary communication.” from the report
Safe recruitment
The home used recruitment checks, including DBS checks and references, before appointing staff.
“People were protected by safe recruitment processes.” from the report
Respectful medicines support
Inspectors observed one staff member giving medicines patiently and in a person-centred way. Trained and assessed staff were allowed to administer medicines.
“They were patient and gentle in their approach, explaining what the medicine was and giving the person time to understand and consent to taking their medicine.” from the report
Choice and dignity
Relatives gave positive feedback about kindness, compassion, dignity and communication. The home supported people to make choices and used least restrictive approaches.
“They treat [loved one] with kindness and compassion and always respectful.” from the report
Medicine records and protocols
seriousMedicine records were incomplete and disordered. There was no MAR for one person’s PRN medicines, and PRN protocols did not always explain when medicines should be given or what symptoms to monitor.
“At this inspection records relating to medicines were incomplete and in a disordered state.” from the report
Staffing levels
seriousThere were not always enough staff to meet people’s needs. Inspectors saw limited contact with one person and another person with a choking risk was not observed or supported at lunchtime.
“The provider had failed to operate a systematic approach to staff deployment which met the needs of people and kept them safe at all times.” from the report
Training and dementia support
seriousSome staff had not received sufficient induction or recent training in dementia and distress. Inspectors found inconsistent approaches and potential risks when people became upset or aggressive.
“Staff were not provided with sufficient induction or training to enable them to carry out their duties.” from the report
Care planning and health risks
seriousImportant information was not always added to care plans after hospital discharge. Staff did not know about one person’s new health condition or the action needed in an emergency.
“There was nothing recorded in the care plan.” from the report
Management checks
seriousAudits and incident monitoring failed to identify several problems, including medicine records, staffing, care plans, dementia support and COVID-19 risk management.
“The provider had failed to establish adequate systems and processes to assess and improve the quality and safety of the service provided or to assess and monitor risks.” from the report
- 01How many care staff will be on each shift, and how will staffing change when people’s needs increase?
- 02How are medicines records and PRN protocols checked now, and how are discontinued medicines removed?
- 03What dementia and distress-support training has each member of staff completed since the inspection?
- 04How are hospital discharge information and new health risks added to care plans before or immediately after a person returns?
- 05What evidence can you show that your audits now identify and correct problems with staffing, medicines and care plans?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 30 September 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, January 2022
Summerley Care Home is rated Requires Improvement; inspectors found risks with medicines, records, staffing and training despite kind care and some improvements.
This was an unannounced, focused inspection outside normal hours. Two inspectors started at 5.30am, spoke with people, staff and relatives, observed care and medication, and checked care, medicine, staff and management records.
The home was not always safe or effective. Medicine records had gaps, risks were not always properly assessed, and infection control practices increased the risk of cross-contamination. Some staff lacked required training and supervision. Staffing pressures meant some people were woken earlier than they wanted.
The home remains rated Requires Improvement. Safe and Effective stayed at Requires Improvement. Well-led fell from Good to Requires Improvement. Caring and Responsive were not inspected during this visit, so their previous ratings were carried forward.
Kind relationships
People and relatives spoke very positively about the caring nature of staff and their relationships with people.
“People told us they were very happy at the service and had good relationships with the staff team.” from the report
Dementia-friendly changes
The home had improved its environment with clearer signs, colour contrasts and more space in the dining area.
“We observed clear, picture and text-based signage around the home and in people's bedrooms, for example to show the clothing in each drawer.” from the report
Communication with relatives
Relatives said they were kept informed about health concerns and changes in people's condition.
“When Mum was poorly, they kept me constantly up to date with what the GP had said and what they were going to do.” from the report
Meal choices
People were offered choices of food and drinks, and menus had been changed to provide more variety.
“We saw people being offered a choice of breakfast, drinks and snacks which they appeared to enjoy.” from the report
Medicine records and checks
seriousMedicine administration was not always recorded. A medicine error was identified almost a month later, so staff could not promptly seek advice or monitor the person's safety.
“One person had been given too much of a medicine, but this had not been identified until almost a month later.” from the report
Incomplete risk information
seriousSome risks were missing, out of date or recorded inconsistently while the home moved from paper to electronic care records. This included mobility and eating and swallowing risks.
“Information was missing and staff did not always know how to access details on how to manage risks in people's care in the new system.” from the report
Staffing pressure
needs fixingStaff said there were not always enough people to provide person-centred care. Some people were woken and got up earlier than they preferred.
“Due to pressures on the staff team, some staff woke and got people up earlier than they would have preferred.” from the report
Training and supervision
seriousSome staff worked for several months without basic training, and some had not received supervision. Mandatory training was not consistently completed or up to date.
“Staff were not provided with sufficient support, training or supervision to enable them to carry out their duties.” from the report
Infection control
needs fixingPPE was not always changed between tasks and hand hygiene was not always completed. Staff moved between care, laundry, cleaning and food handling, increasing the risk of cross-contamination.
“The lack of appropriate PPE changes and hand hygiene increased the risk of bacteria spreading to food from hands or uniform.” from the report
Weak management checks
needs fixingAudits and records were incomplete, and identified actions were not always completed promptly or thoroughly. This reduced confidence that problems were being found and fixed.
“Where improvements were identified in audits, actions had not always been taken in a timely or thorough way.” from the report
- 01How many care staff are normally on duty during the day and at night, and how do you cover vacancies or sickness?
- 02How do you now check that every medicine dose, cream and patch application is recorded correctly?
- 03How are changes in mobility, swallowing, eating and drinking risks recorded and shared with all staff?
- 04Which staff have completed their required training and regular supervision?
- 05What checks now make sure accidents, bruises and other incidents are recorded and reviewed for patterns?
This was a focused, unannounced out-of-hours inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 13 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 Summerley Care Home
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Good
- June 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- August 2011
Registered with the Care Quality Commission on 12 August 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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These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,170 a week. 23 can care for a couple. 11 years' experience on average.
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