CQC report explained · a residential care home
What the CQC found at Summerville House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe medicines management, suitable risk assessments and improvements in safeguarding and incident reviews.
- Effective?
- Requires improvement
- Care and support did not always achieve consistent good outcomes because some mental capacity and legal authority records were inaccurate. Other improvements included better training, food choices and support from health professionals.
- Caring?
- Good
- Staff were described and observed as kind, respectful and supportive of people's dignity, choices and independence.
- Responsive?
- Good
- Care plans and activities had improved, and staff were said to know people's preferences and communication needs. Complaints were investigated promptly.
- Well-led?
- Good
- Inspectors found stronger leadership, staff support and quality checks under the new registered manager. Improvement work was continuing with action plans and audits.
What inspectors found, April 2020
Rated Good overall; inspectors found safe, kind and responsive care, but the Effective rating Requires Improvement because some decision-making records were inaccurate.
This was an unannounced planned inspection on 25 February 2020. Inspectors spoke with people living in the home, relatives and staff. They reviewed care, medicines, recruitment and management records, including four people's care records.
The home was rated Good overall. Safe, Caring, Responsive and Well-led were rated Good. Inspectors found enough staff, safe medicines practice, clean surroundings, kind care and better activities. They also found improvements in food choices, staff training and the environment.
Effective remained Requires Improvement. Records did not always accurately show when people lacked capacity or who had legal authority to make decisions for them. The home had started to correct this. The previous overall rating was Requires Improvement with multiple breaches, but inspectors found the home was no longer breaching regulations at this inspection.
Safe staffing
Inspectors saw enough staff on duty to meet people's needs without unnecessary waiting. Recruitment checks had also improved.
“We observed there were enough staff on duty to meet people's needs in a timely way.” from the report
Kind and respectful care
Staff promoted dignity, privacy and independence. They knew people's histories and preferences and used this knowledge in their care.
“Staff were kind, caring and took time to promote people's independence.” from the report
Better activities
The home had improved the range and frequency of activities, including meaningful activities for people living with dementia.
“There was now a regular programme of events that people could join in, including events off site” from the report
Improved leadership
The report describes major improvements in leadership, training, the environment, mealtimes and activities. Quality audits were being used to identify and address shortfalls.
“There was a robust quality assurance system in place.” from the report
Decision-making records
needs fixingSome records did not clearly or accurately show when people lacked mental capacity or who had legal authority to make decisions for them. The manager had begun reviewing all related records, but the process was still at an early stage.
“There had been an inconsistent approach to managing and reviewing the assessment of people's mental capacity and the decisions needing to be made on their behalf.” from the report
- 01How have you completed the review of mental capacity records since this inspection?
- 02How do you record who has legal authority to make health, welfare or financial decisions for each person?
- 03What staffing levels are normally in place, and have the increased staffing levels continued?
- 04What activities are currently available for people living with dementia?
- 05How do you check that staff training in moving and handling, medicines and food safety remains up to date?
This was an unannounced planned inspection covering all five CQC questions, including both the care provided and the care home premises. This explanation was written from the published report of 10 April 2020 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 2019
Summerville House was rated Requires Improvement in every area, with concerns about safety, staffing, consent, activities and management checks.
This was an unannounced, comprehensive inspection on 14 January 2019. Inspectors reviewed care and medicine records, staff recruitment and training records, and the provider's quality checks. They also spoke with people, relatives, staff and managers, and observed care.
The home was not consistently safe, effective, caring, responsive or well-led. Inspectors found that risks were not always assessed, planned staffing levels were not consistently met, and some staff used unsafe or unsuitable care techniques. People did not always receive choice and consent was not always properly obtained.
People had too little meaningful activity and the dining experience needed improvement. Quality checks had failed to identify several problems, including safety risks, staff practice, staffing gaps and missed notifications to CQC. The provider was in breach of five regulations.
The overall rating fell from Good at the previous inspection to Requires Improvement. The report says the manager later corrected the thickener instructions and confirmed that all night staff had received medicines training.
Medicines usually on time
People generally received their medicines when needed. Medicines were stored securely and records showed that doses had been given as required.
“People received their medicines when they needed them.” from the report
Quick medical response
When people became unwell, staff sought appropriate medical advice promptly.
“When people became unwell, the staff acted quickly to ensure they received the appropriate medical advice.” from the report
Open culture
Relatives and staff said the manager was approachable. People and relatives were asked for their views and felt able to raise concerns.
“There was an open culture in the home.” from the report
End-of-life support
The home sought people's wishes where possible and worked with specialist professionals to support comfort and dignity at the end of life.
“This helped ensure they were comfortable, dignified and pain free at the end of their lives.” from the report
Unmanaged safety risks
seriousSome risks were not assessed or controlled. Inspectors also saw incorrect thickener being used and unsafe moving techniques, creating a risk of avoidable harm.
“Risks to people's safety had not always been assessed or managed appropriately placing them at risk of avoidable harm.” from the report
Staffing gaps
seriousThe extra staff shift needed between 4pm and 6pm was filled on only two of the 14 days checked. Staff said they had little time to engage with people.
“There were not always sufficient numbers of suitably qualified, competent, skilled or experienced staff deployed to meet people's needs.” from the report
Consent and choice
seriousStaff did not always ask before moving people or providing care. Required mental capacity assessments and best-interest decisions were missing for some decisions.
“Consent had not always been sought in line with the relevant legislation.” from the report
Too little stimulation
seriousPeople spent much of their time sitting or walking around, and inspectors saw no activities on the inspection day. Records did not show activities for some people during the previous 14 days.
“People continued to lack daily stimulation and people's social needs were not always being delivered.” from the report
Weak management checks
seriousAudits had not identified several safety, staffing, consent, recruitment and activity problems. Some required incidents had also not been reported to CQC.
“Not all the current systems and processes in place to monitor the quality of care provided and to mitigate risks to people's safety had been effective.” from the report
Mealtime experience
needs fixingPeople were not offered a choice of food, some received limited encouragement to eat, and fluid records were not always reliable.
“People were offered a choice of drink but not a choice of food.” from the report
- 01What has been done to make sure all risks, including unsecured creams and razors, accessible stairs and bed rails, are assessed and managed?
- 02How do you ensure the planned staffing levels, especially between 4pm and 6pm, are met every day?
- 03What face-to-face dementia and moving-and-handling training has staff completed, and how is their practical competence checked?
- 04How do you make sure people are asked for consent and that mental capacity and best-interest decisions are recorded?
- 05What activities are now available each day for people living with dementia, and how are individual interests reflected in care records?
This was a comprehensive inspection covering the premises and care provided, with ratings given for all five questions. This explanation was written from the published report of 22 February 2019 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 Summerville House
5 rated inspections over 5 years: the service has held its Good rating throughout.
- April 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- February 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- March 2016Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- August 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
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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13 live-in carers within about an hour of Norfolk
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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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