CQC report explained · a residential care home
What the CQC found at Sunningdale EMI Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- People were generally protected by safe staffing, safeguarding systems, risk assessments and medicines arrangements. However, accident and incident records were not always completed correctly, and records for rotating pain patches were missing.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Well-led?
- Good
- Inspectors found effective quality checks, detailed care plans, positive leadership and an open culture. The home acted on feedback and showed a focus on learning from problems.
What inspectors found, March 2023
Rated Good overall, but inspectors found that safety records were not always complete and rated Safe as Requires Improvement.
This was an unannounced focused inspection. Inspectors visited on 28 February 2023 and completed inspection work up to 8 March 2023. They spoke with people, relatives and staff, and reviewed care, medicines, staffing and management records.
The home had enough staff, trained workers and systems to protect people from abuse. Medicines were given as prescribed, but records about accidents, incidents and pain patches were not always complete. Inspectors made recommendations, and the provider said it acted immediately on these points.
The home was well-led. Inspectors found effective checks on quality, detailed care plans, kind interactions and positive feedback from people, relatives and staff. The overall rating improved from Requires Improvement at the previous inspection to Good, and the previous breaches were no longer in place.
Staffing and training
A staffing tool was being used, and inspectors saw enough staff to meet people's needs safely. Staff received induction, training and competency checks.
“A staffing dependency tool was in place and being used to calculate and maintain safe staffing levels in the service.” from the report
Kind and respectful care
Inspectors saw kind interactions. Staff knew people well and treated them with dignity and respect.
“We observed kind, caring interactions from staff with people. Staff knew people well and treat them with dignity and respect.” from the report
Leadership and quality checks
The management team had consistent audits and used them to identify improvements. Care plans contained detailed background information and risk assessments.
“The provider had effective quality assurance systems in place, with audits being completely consistently and identifying areas for improvement.” from the report
Listening and responding
The home gathered views through surveys, meetings and a suggestion box. Inspectors saw evidence that feedback led to changes.
“We saw action was taken in response to feedback people and relatives gave on ways to improve the service.” from the report
Accident and incident records
needs fixingStaff did not always complete the electronic reporting system correctly. This meant managers did not have a full picture of incidents when reviewing them.
“However, the management team did not always have an accurate overview of what was happening at the service because staff were not always completing the electronic recording system correctly.” from the report
Pain patch records
needs fixingThere was no record showing where the previous pain patch had been applied. This made it difficult to check that patches were rotated as instructed, although inspectors found no evidence of harm.
“Where people were prescribed medication in the form of patches there was no document for staff to detail where the last patch had been applied.” from the report
Support when people became distressed
needs fixingGuidance for staff on supporting people who became distressed was not comprehensive. The provider said assessments and guidance would be reviewed.
“However, guidance on how staff should support each person to manage this was not comprehensive.” from the report
Recording restrictions
needs fixingOne person's records did not explain restrictions about cigarettes and alcohol. The provider took immediate action to review the care plan and assessments.
“However, the person's care records did not include any information about these restrictions.” from the report
- 01How are you checking that all accidents and incidents are now recorded correctly?
- 02How do staff record the position of each pain patch, and how is rotation checked?
- 03What new guidance is in place for supporting people when they become distressed?
- 04How are restrictions about alcohol, cigarettes or other choices recorded in each person's care plan?
- 05Which ratings were carried forward from the previous inspection rather than checked during this visit?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 21 March 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 2021
Rated Requires Improvement; inspectors found risks in medicines, staffing records and management systems, although care was kind and respectful.
This was an unannounced focused inspection. Inspectors visited on 10 August 2021 and reviewed information, records and medicines. They also spoke with people, a relative and staff. The inspection activity ended on 18 August 2021.
The home was not always safe. Some people did not receive medicines as prescribed, medicines records were not always accurate, and medicines were not always stored safely. Staffing levels were sometimes below the home's stated need, although inspectors did not see an impact on people during the visit.
The home was also not well-led. Audits and other checks had failed to find problems with medicines, care plans and safeguarding. Care plans were not always up to date. Inspectors found breaches of regulations about safe care and treatment and good governance.
The overall rating fell from Good at the previous inspection to Requires Improvement. This inspection looked only at Safe and Well-led. The other ratings were carried forward from the previous comprehensive inspection.
Kind and respectful care
Inspectors saw positive interactions. People and relatives gave positive feedback about how staff treated them.
“Staff were kind and caring. We observed positive interactions between staff and people.” from the report
People's views were heard
People were asked for their views and suggestions. The home acted on feedback, including a request about the front of the home.
“The minutes demonstrated people were involved in making decisions about the service.” from the report
Safe recruitment
Staff recruitment checks were completed safely. Training and supervision had improved.
“Staff training had improved with supervisions in place, and staff were recruited safely.” from the report
Clean premises and PPE
Inspectors found the premises clean and were assured that several infection control arrangements were in place.
“We were assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Medicines were not always safe
seriousPeople did not always receive medicines as prescribed. One person missed medication for up to nine days, and some storage and recording arrangements were incomplete.
“People did not always receive their medication as prescribed. For example, one person had missed their medication for up to nine days.” from the report
Weak management checks
seriousAudits did not find problems that inspectors identified. The home did not have effective arrangements for learning from incidents and preventing them happening again.
“Governance systems were not always effective. Audits for medication, care plans and safeguarding did not identify issues and drive improvements at the service.” from the report
Staffing levels needed clearer checks
needs fixingThe home did not use a dependency tool to work out staffing needs. Records showed staffing was below the provider's stated level on 16 days in a three-week period.
“We recommend the provider uses a dependency tool for determining safe staffing levels.” from the report
Care plans were out of date
needs fixingCare plans did not always reflect people's current needs, including details about hoisting.
“Care plans were not up to date and did not reflect people's current needs.” from the report
Some infection control rules were missed
minorSome staff wore watches, so they were not bare below the elbow. There were also no hand-washing facilities at the visitor entrance, although hand sanitiser was available.
“We observed some staff wearing watches, so they were not bare below the elbow.” from the report
- 01What changes have you made to ensure every medicine is given as prescribed and recorded accurately?
- 02How do you now check that medicines, creams, thickeners and supplements are stored and administered safely?
- 03How do you calculate the number of staff needed on each shift, especially at night?
- 04How are care plans checked and updated when a person's needs change?
- 05What action have you taken so incidents and audit findings lead to recorded improvements?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 5 October 2021 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 Sunningdale EMI Care Home
7 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2016Requires improvementup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2016Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 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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