CQC report explained · a nursing home
What the CQC found at Sunhill Court Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found a significant safeguarding concern and made a referral to the relevant safeguarding authority. Medicines were not always managed safely, although staffing, recruitment and some risk management were satisfactory.
- Effective?
- Requires improvement
- People were supported with their diet, healthcare and legal consent. However, several people waited a long time for lunch, causing distress and anxiety.
- Caring?
- Good
- This question was not inspected during this focused visit. Inspectors did observe kind, gentle and personalised interactions between people and staff.
- Responsive?
- Good
- This question was not inspected during this focused visit. The report says people’s preferences were considered in areas such as menus and individual support.
- Well-led?
- Requires improvement
- Management checks did not reliably identify risks, cleaning problems, unsafe medicines practice or inaccurate care records. Abuse or alleged abuse was not always notified to CQC as required.
What inspectors found, August 2023
Rated Requires Improvement; inspectors found kind and personalised care, but serious safeguarding, medicines and management concerns.
This was an unannounced focused inspection on 30 June 2023. Inspectors looked at whether the home was safe, effective and well-led. They spoke with people, a relative, staff and healthcare professionals, and reviewed care plans, medicines records, recruitment files and management records.
Inspectors made a safeguarding referral after finding significant concerns about one person’s safety. They also found medicines were not always managed safely. Eye drops were left unsecured on top of a medicines trolley, hand hygiene was missed between people, and one person was not supervised to make sure they had taken all their medicine.
Some areas were not clean or well maintained. Nine people waited at least 30 minutes for their lunch, which caused distress and anxiety for some. Risk records were not always accurate, and audits had failed to identify several problems.
The overall rating changed from Good to Requires Improvement. Safe, Effective and Well-led were all rated Requires Improvement. The inspection did not assess Caring or Responsive, so those areas were not reviewed in this visit.
Enough trained staff
Inspectors found enough trained staff to meet people’s needs. Recruitment checks were also completed safely.
“There were sufficient trained staff on duty to meet people's needs.” from the report
Kind and personalised support
People received personalised care, and staff were observed responding with kindness, gentleness and distraction when people became distressed.
“People received personalised care and we observed positive interactions between people and staff.” from the report
Healthcare support
The home worked with GPs, therapists, dieticians and other professionals when people needed additional support.
“People received support from a range of health and social care professionals.” from the report
Accessible surroundings
The layout, signage, lift and some equipment supported people living with dementia and people with mobility needs.
“The premises had been adapted to meet people's needs.” from the report
Safeguarding concern
seriousInspectors were not satisfied that one person was protected from the risk of abuse or harm. They made a safeguarding referral during the inspection.
“We were not satisfied the person was protected from the risk of abuse or harm and we made a referral to the relevant safeguarding authority during the inspection.” from the report
Unsafe medicines practice
seriousInspectors saw missed hand hygiene, eye drops left unsecured and a medicine given in food without checking that it had all been taken.
“The provider had failed to ensure the safe management of medicines.” from the report
Long waits for lunch
needs fixingNine people waited at least 30 minutes for their meal. This caused distress and anxiety for some people.
“Nine people waited at least 30 minutes before they received their meal, and this caused distress and anxiety for some.” from the report
Weak risk and quality checks
needs fixingAudits did not identify several problems, and some risk assessments were contradictory or lacked clear guidance for staff.
“The way risks were assessed and documented within the electronic care planning system was not reliable or accurate.” from the report
Cleaning and maintenance
needs fixingInspectors found food debris, liquid splashes, an uncovered drain and flooring that created a trip hazard. Some issues were addressed during or after the inspection.
“In 2 rooms we found food debris on the floor and in 1, liquid splashes on the walls.” from the report
- 01What action has been taken following the safeguarding referral, and how are people now protected from similar risks?
- 02How are medicines now checked, including hand hygiene, secure storage of eye drops and confirming that medicines given in food have been taken?
- 03What has changed to prevent people waiting too long for meals?
- 04How are risk assessments checked for accuracy, especially where people have choking or alcohol-related risks?
- 05What improvements have been made to cleaning, bathroom flooring and the management audit system?
This was an unannounced focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and the report used previous ratings for any questions not inspected. This explanation was written from the published report of 19 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, February 2022
Sunhill Court Nursing Home was inspected but not rated; inspectors found good infection-control arrangements but missing individual COVID-19 risk assessments.
This was an announced, targeted inspection on 21 January 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected care.
Inspectors were assured about visiting, admissions, personal protective equipment, testing, hygiene, outbreak management and vaccination checks. The home also had a detailed COVID-19 contingency plan and systems for families to book visits.
Inspectors were only somewhat assured about shielding and social distancing, and about whether the infection-control policy was up to date. The home had not completed individual COVID-19 risk assessments for staff or residents, although managers said they would start doing this straight away.
The home was inspected but not rated. This means the report does not give a standard overall rating or full ratings for the five areas of care.
Family visiting
The home provided a way for families and friends to arrange visits online or by telephone.
“The provider facilitated safe visiting arrangements by enabling people's families and friends to book a visit online or by telephone.” from the report
Outbreak planning
The home had a detailed plan for managing future COVID-19 outbreaks and reducing infection spread.
“The provider had a detailed contingency plan setting out how to handle any future COVID-19 outbreaks and how to minimise the risk of spread of the infection.” from the report
Staff recognition
The provider recognised staff commitment and contribution during the COVID-19 pandemic.
“The provider had actively recognised the commitment and contribution of staff during the COVID-19 pandemic and ensured the team benefitted from various recognition schemes.” from the report
Individual infection-risk assessments
needs fixingThe home had not systematically assessed COVID-19 risks for individual staff members or residents. Managers acknowledged this and said they would begin the assessments straight away.
“The provider had not carried out individual risk assessments for staff or people using the service in relation to COVID-19.” from the report
Policies and practice
needs fixingSome infection-control policies, procedures and practices were not fully in line with current guidance. Inspectors were also only somewhat assured about shielding and social distancing arrangements.
“Policies, procedures and practices were not fully in line with current government guidance and the Health and Social Care Act 2008: code of practice on the prevention and control of infections.” from the report
- 01Have individual COVID-19 risk assessments now been completed for every resident and staff member?
- 02How are individual infection risks recorded, reviewed and acted on when circumstances change?
- 03What changes have been made to bring the infection-control policies and procedures in line with current guidance?
- 04How does the home make sure shielding and social-distancing arrangements are followed in practice?
- 05What measures are in place if COVID-19 causes staff shortages, and how could this affect care?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 17 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 Sunhill Court Nursing Home
6 rated inspections over 8 years: the service has improved, from Inadequate to Requires improvement.
- August 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- April 2020Goodup from Requires improvementSafe: Requires improvementEffective: GoodWell-led: Good
- April 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2015InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- September 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 January 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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