CQC report explained · a nursing home
What the CQC found at Sunningdale Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people were protected from abuse and avoidable harm. Risks were assessed, staffing and recruitment were safe, medicines were managed safely, and infection control arrangements were suitable.
- Effective?
- Good
- People's needs and preferences were assessed and care plans were regularly reviewed. Staff were trained, nutrition needs were met, healthcare support was available, and consent arrangements followed the law.
- Caring?
- Good
- This key question was not inspected during this visit. The previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. The previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found approachable leadership, clear staff roles and effective quality checks. People, relatives and staff were asked for feedback, and the home worked with other professionals.
What inspectors found, March 2022
Rated Good; inspectors found safe, effective and well-led care, with Safe improving from Requires Improvement.
This was an unannounced inspection on 2 March 2022. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, medicines records, recruitment and training files, and management records.
The home was rated Good overall. Inspectors found people were protected from abuse and avoidable harm, received medicines safely, and lived in a clean home with suitable infection control. Staff understood people's needs and risks.
People's care plans reflected their needs and choices. Their food and drink needs were met, staff helped them access healthcare, and consent was sought. Inspectors also found strong management systems and an open culture.
This inspection covered Safe, Effective and Well-led. The ratings for these areas were Good. Caring and Responsive were not inspected during this visit, so their previous ratings were used when calculating the overall rating.
Safe care
People and relatives told inspectors they felt safe. Staff were trained to recognise and respond to abuse, and risks were recorded with clear actions to reduce them.
“People were protected from the risk of harm and abuse by well trained staff who knew people's needs well.” from the report
Medicines
Inspectors found that medicines were given as prescribed and at the right times. Records and medicine stocks matched, including for controlled drugs.
“People received their medicines safely as prescribed. We observed people receiving time specific medicines in line with their assessed health needs.” from the report
Food and nutrition
People's dietary needs, preferences and specific nutritional requirements were recorded. Inspectors saw people receiving suitable food and drinks, with regular choices available.
“People told us they liked the food on offer and were given a choice of meals, drinks and snacks regularly.” from the report
Management checks
The home had regular audits and clear actions where improvements were needed. The management team was described as approachable, and people and relatives could give feedback.
“There were effective quality assurance systems in place. Audits were regularly completed, and actions and timescales were put in place where follow up was required.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you continue to monitor and reduce risks for my relative, and how will changes in their needs be recorded?
- 02How do you check that medicines are given at the right time and that records remain accurate?
- 03How will you support my relative's food, drink and hydration needs, particularly if their needs change?
- 04What arrangements are currently in place for visits and infection control?
- 05What was the previous rating for Caring and Responsive, and what improvements have been made in those areas since then?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 17 March 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, July 2019
Rated Good overall, but safety Requires Improvement because some safety checks and care records were not always complete.
This was an unannounced inspection over 1 and 2 July 2019. The inspector spoke with people living in the home, relatives, staff and a healthcare professional. They reviewed care records, medicines records, staff files and safety and quality checks.
People and relatives gave very positive feedback. Inspectors found a warm, welcoming home with kind staff, enough staff to meet people's needs, good activities and strong support for families. Care was generally personal and respectful.
The main weaknesses were in safety checks and record keeping. Some checks, including water temperature checks, had not been done regularly. Records about wounds, pressure sores and some health interventions needed to be clearer. The provider acted on the issues and sent evidence that outstanding safety checks had been completed.
The overall rating was Good. Effective, Caring, Responsive and Well-led were rated Good. Safe was rated Requires Improvement, which means some aspects of safety were not always reliable, even though people said they felt safe.
Kind and respectful care
Inspectors found a warm and inclusive atmosphere. Staff supported people and relatives with unusual kindness, including during difficult times and at the end of life.
“We found a truly positive, inclusive, warm and welcoming atmosphere throughout our inspection.” from the report
Activities and social contact
The home had invested heavily in activities, including personalised support for people in their bedrooms and regular trips into the community.
“They had significantly invested into the activities on offer with a remarkable 167 hours provided weekly.” from the report
Staffing and teamwork
Inspectors found enough staff to meet people's needs. Staff reported feeling supported and part of a consistent team, with no agency staff used since 2016.
“There were enough staff to meet people's needs and people overall did not have to wait a long time to be assisted.” from the report
Good support for families
Relatives were kept informed and supported. The home worked closely with families when people were receiving end of life care.
“They look after us [the relatives] all of the time, making sure we have plenty to eat and drink.” from the report
Improvement after the previous inspection
Effective care improved from Requires Improvement to Good. The home had acted on earlier advice about assessing people's capacity for specific decisions.
“At this inspection we found the provider had done this and improvements had been made.” from the report
Safety checks were not always completed
seriousSome checks, including water temperature checks, had not been completed or repeated regularly. The provider later sent evidence that these checks had been completed.
“Some safety checks had not been completed or not been completed regularly, such as water temperature checks.” from the report
Care records needed to be clearer
needs fixingRecords about wounds and pressure sores did not give inspectors enough assurance about ongoing monitoring. Other health intervention records also needed updating.
“We identified improvement needs to the recording of wound and pressure sore management with the registered manager.” from the report
Audits missed some gaps
needs fixingThe home's checks of its own quality and safety systems had not identified all the missing checks and records. Managers acted when inspectors raised the issues.
“The registered manager and provider were also open and honest about the fact that audits had not identified some gaps in safety checks and records.” from the report
Some assessments needed more detail
minorMental capacity assessments had improved but needed to be more robust when a person's capacity could change. Some best-practice health records and care plans also needed updating.
“However, we discussed that these needed to be more robust when people might have fluctuating capacity.” from the report
- 01What evidence can you show that water temperature and other safety checks are now completed at the required frequency?
- 02How do you record and review wound and pressure sore care, and how do you make sure changes are acted on promptly?
- 03How do you check that care records and health intervention records are complete and up to date?
- 04How do you assess and review capacity when a person's ability to make a decision may fluctuate?
- 05What changes have been made to audits so they identify missing safety checks and records?
This was a planned, unannounced inspection covering all five key questions; Safe deteriorated from Good to Requires Improvement, while Effective improved from Requires Improvement to Good. This explanation was written from the published report of 27 July 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 Sunningdale Nursing Home
6 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- March 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2019Goodstayed GoodSafe: Requires improvementEffective: GoodWell-led: Good
- January 2017Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2016Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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