CQC report explained · a residential care home
What the CQC found at Sun Woodhouse Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- The lift had not been maintained within the recommended timescale, although the provider supplied evidence that the work was completed in July 2023. Inspectors also found gaps in topical cream records and some staff were unclear about fire responsibilities.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward.
- Well-led?
- Good
- Inspectors found supportive leadership, audits, care plan reviews and evidence that lessons were learned. Staff said the culture and leadership had improved.
What inspectors found, August 2023
Rated Good overall; inspectors found kind, well-supported care, but Safe was Requires Improvement because of lift safety checks and recording gaps.
This was an unannounced inspection on 19 June 2023. One inspector and an Expert by Experience spoke with people living at the home, staff and managers. They observed care and reviewed care, medicine and recruitment records.
The home was rated Good overall. Safe was rated Requires Improvement and well-led was rated Good. The report says the lift had not been maintained as recommended, although the work was completed in July 2023 after the inspection.
People generally said they felt safe and received kind care. Staffing levels, recruitment, safeguarding, infection control and most medicines arrangements were good. Inspectors found some gaps in recording topical creams, and some staff were unclear about what to do in a fire.
The inspection covered Safe and well-led. Ratings for the other three questions were carried forward from the previous inspection. The report also contains a conflicting statement saying the overall rating had changed to Requires Improvement, although its rating table lists the overall rating as Good.
Enough staff
Inspectors found enough staff to meet people's needs. Staff were visible and responded promptly when people needed help.
“There were sufficient numbers of staff to meet people's needs.” from the report
Kind and attentive care
People described staff as supportive and said they were listened to and able to control their daily routines.
“Staff were very attentive in asking people if they were okay and if they needed anything.” from the report
Safe medicines systems
Medicines were stored securely and staff giving them had training and regular competency checks. People received their medicines as prescribed.
“People received their medicines as prescribed from staff who had received training for this and had their competency checked annually.” from the report
Supportive leadership
Inspectors found that the manager understood people's needs and used audits and walkarounds to check standards. Staff said the culture had improved.
“Staff told us the culture in the home had improved over the months since the home manager joined.” from the report
Good safeguarding practice
Staff understood the signs of abuse and how to report concerns. Safeguarding incidents were recorded, reviewed and acted on.
“Staff were able to describe signs of abuse they would be looking for.” from the report
Lift maintenance
seriousThe lift needed work within one month, but this had not happened by the inspection. The provider said the work was completed in July 2023.
“The lift had not been adequately maintained, which placed people at risk due to this equipment safety check having not been completed as per recommended guidance.” from the report
Fire responsibilities
needs fixingSome staff could not clearly explain what they were responsible for during a fire. This was raised with the manager, who took immediate action.
“Some staff were not clear about their responsibilities in the event of a fire.” from the report
Topical cream records
needs fixingThere were gaps in records showing when topical creams had been applied. People told inspectors the creams were being given as prescribed.
“Some gaps were seen in recording the administration of topical creams.” from the report
Special dietary meal
needs fixingOne person was given food that did not meet their specific dietary need at lunchtime. The manager said this should not have happened and dealt with it after the inspection.
“One person had a specific dietary need.” from the report
- 01What evidence can you show that the lift work was completed and that future safety checks are now up to date?
- 02How have you made sure every staff member understands their role during a fire, including for people who need help to evacuate?
- 03How do you now record and check the application of topical creams?
- 04How will you make sure meals always meet each person's specific dietary needs?
- 05Has the home manager completed their registration with the CQC?
This was an unannounced focused inspection of Safe and well-led; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 10 August 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, August 2019
Rated Good; inspectors found safe, kind and personalised care, with some risk records needing more detail.
This was a planned inspection after a change to the home's registration. The first visit was unannounced and took place on 15 and 16 July 2019. Inspectors spoke with people, relatives, staff and a healthcare professional. They observed care and checked care, medicine, staff and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, suitable training, kind care and a varied activities programme.
Some risk assessments and care plans did not contain enough detail. This included equipment used during showers and how risks from one person's behaviour were managed. The home updated these records immediately, and inspectors said this had not affected people using the service.
Safe medicines
Inspectors found that medicines were given as prescribed and records were accurate. Staff had training and yearly competence checks.
“Staff kept accurate records of all medicines ordered, given and disposed of.” from the report
Kind, respectful care
People and relatives consistently described staff as kind. Inspectors also observed respectful and helpful interactions.
“We observed kind and helpful interactions between staff and people.” from the report
Activities and interaction
The home offered regular activities and staff spent time engaging with people. Inspectors saw singing and indoor bowling taking place.
“There was a regular and varied programme of activities to promote people's wellbeing and interaction.” from the report
Staffing and training
People felt there were enough staff, and inspectors found safe recruitment checks, induction, ongoing training and supervision.
“There were enough staff on each shift to support people and robust recruitment checks were carried out before staff started working at the service.” from the report
Risk records needed more detail
needs fixingSome risk assessments and care plans did not clearly explain equipment used during showers or how risks from one person's behaviour were managed. The home updated the records during the inspection.
“Some risk assessments required further detail.” from the report
- 01How are individual risk assessments and care plans kept detailed and up to date?
- 02How would you manage risks if a person became unsettled or their behaviour posed a risk to others?
- 03How do you make sure there are enough staff when people's needs change, particularly during the evening?
- 04What activities are available for someone living with dementia, and how are their personal interests included?
- 05How will you involve our family member and us in reviewing their care plan?
This was a planned inspection covering all five CQC areas after a change to the home's registration; the first visit was unannounced. This explanation was written from the published report of 14 August 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 Sun Woodhouse Care Home
2 rated inspections over 4 years: the service has held its Good rating throughout.
- August 2023Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2019GoodSafe: GoodWell-led: Good
- July 2018
Registered with the Care Quality Commission on 16 July 2018.
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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