CQC report explained · a residential care home
What the CQC found at Sunnycroft Care 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 that risks to people's safety were not always assessed or managed. Safeguarding investigations and reporting were also not always timely or effective.
- Effective?
- Requires improvement
- This question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Requires improvement
- This question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Inadequate
- Inspectors found weak systems for checking care quality, missed safeguarding and health and safety concerns, and failures to notify CQC about incidents. Staff gave mixed views about the culture and whether they could raise concerns safely.
What inspectors found, September 2021
Rated Requires Improvement; inspectors found safety shortfalls and inadequate leadership, including risks not properly managed.
This was an unannounced focused inspection on 13 and 23 July 2021. Inspectors looked at Safe and Well-led because of concerns about safeguarding and the culture in the home. They spoke with people, relatives and staff, and checked care, medicine, recruitment and management records.
The home was rated Requires Improvement overall. Safe was Requires Improvement and Well-led was Inadequate. Inspectors found that some risks were not properly assessed or managed, safeguarding concerns were not always dealt with quickly, and some incidents were not reported to the right authorities.
There were enough staff to keep people safe, but not enough time for meaningful activities and social interaction. Medicines, cleanliness and infection control were found to be generally safe. Relatives were mostly positive about the care, but staff gave mixed views about whether they felt valued or able to raise concerns.
The home had also been rated Requires Improvement at its previous inspection in 2019. It has held this rating for four consecutive inspections, and the report says previous improvements had not been enough.
Medicines
People received their medicines when needed. Medicines were stored securely, and staff had training and competency checks.
“Records showed people had received their medicines when they needed them. They were stored securely for the safety of people living in the service.” from the report
Infection control
Inspectors found adequate systems to prevent infection, including appropriate use of protective equipment, testing and cleaning arrangements.
“We were assured that the provider was using PPE effectively and safely and that they were accessing testing for people using the service and staff.” from the report
Relatives' views
Relatives spoken to were generally happy with the care and said management was approachable.
“The care given to my relative is excellent and [Family member] is quite happy and likes the carers. The staff are kind and do a good job.” from the report
Unmanaged safety risks
seriousSome people's risks were not properly assessed or acted on. This included significant weight loss and risks linked to distressed behaviour.
“Risks to people's safety had not always been adequately assessed or managed, placing them at risk of harm.” from the report
Unsafe garden
seriousThe garden had trip hazards, exposed broken glass and gaps leading towards a busy road. The provider took steps to reduce the risks during the inspection.
“There were missing fence panels next to a neighbouring property and three low gates that led to a busy main road.” from the report
Safeguarding response
seriousOne safeguarding allegation was not investigated until nine days after it was raised. Not all allegations were reported to the local authority or CQC.
“Staff had raised one allegation to a senior staff member on 3 April 2021, but this had not been investigated until 12 April 2021.” from the report
Unlawful restriction
seriousInspectors found that restrictions had been used without proper consideration of the legal safeguards. This meant one person was unlawfully deprived of their liberty.
“This had resulted in one person who the registered manager told us lacked capacity to consent to these restrictions, being unlawfully deprived of their liberty.” from the report
Weak quality checks
seriousThe provider's systems did not reliably identify problems or learn from incidents and complaints. This included missed concerns in the garden and a hazardous room.
“Governance systems were not robust at monitoring or improving the quality of care. This placed people at risk of harm.” from the report
Limited activities and staff morale
needs fixingStaff had enough time to meet basic care needs but not enough time for meaningful engagement. Some staff said they felt undervalued or afraid to raise concerns.
“Most staff said they did not have adequate time to engage meaningfully with people.” from the report
- 01What has been done to make the garden safe and secure, including the raised patio stones, broken greenhouse, missing fence panels and low gates?
- 02How are safeguarding allegations now investigated, recorded and reported to the local authority and CQC?
- 03How do you check that people's risks, including nutrition risks and risks from distressed behaviour, are reviewed and acted on?
- 04What legal checks are completed before restrictions are used for someone who may lack capacity to consent?
- 05What has changed to give staff more time for activities and meaningful interaction, and to help staff raise concerns without fear of reprisals?
This was a focused inspection of Safe and Well-led only; the other key question ratings were not inspected and carried over from previous comprehensive inspections. This explanation was written from the published report of 7 September 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.
What inspectors found, May 2019
Sunnycroft Care Home was rated Requires Improvement; inspectors found kind, responsive care but gaps in risk records, mental-capacity checks and management oversight.
This was an unannounced inspection on 08 April 2019. Inspectors spoke with people living in the home, a relative and staff. They observed care and looked at five people's care records and other records about how the home was run.
The home was not always safe, effective, caring or well-led. Risk assessments and daily care records were incomplete or out of date. Mental-capacity assessments were missing when needed. Staff did not always protect people's dignity.
There were also positive findings. People said they felt safe, there were enough staff, medicines were generally given and recorded safely, and people enjoyed the food and activities. Responsive care was rated Good.
The overall rating was Requires Improvement, as it had been at the previous two inspections. Cleanliness, activities and some personalised care had improved, but further work was still needed.
Medicines
Medicines were generally stored securely and given as prescribed, with records and checks in place.
“Medicines were given by staff and recorded on medicine administration records appropriately.” from the report
Staffing
Inspectors saw staff available during the visit, and people and relatives said there were enough staff to meet people's needs.
“People and relatives told us there were enough staff to meet people's needs, and we saw staff available to people throughout our inspection.” from the report
Cleanliness
The standard of cleanliness and the cleanliness of equipment had improved substantially since the previous inspection.
“There had been significant improvements in the standard of cleanliness in the home since our last inspection and we found the home, and equipment people used, was clean.” from the report
Activities
Activities had improved and people could take part in hobbies, interests and visiting entertainment.
“Activities provision was much improved since the last inspection and people had access to a range of activities.” from the report
Kind interactions
Inspectors observed patient and caring interactions, and people described staff as kind and compassionate.
“We saw patient, kind and caring interactions take place between staff and people throughout the day.” from the report
Incomplete risk information
seriousRisk assessments were not always individualised, accurate or updated quickly. This included pressure care, choking, self-medication and emergency evacuation plans.
“Risk assessments were not updated in a timely manner.” from the report
Missing mental-capacity checks
needs fixingThe home had not completed decision-specific mental-capacity assessments when people might not be able to make decisions for themselves. This included a person receiving medicines covertly.
“There were no decision specific mental capacity assessments for people when there was a doubt about their capacity.” from the report
Care records and monitoring
seriousFood, fluid, personal care and other daily records were not consistently completed or checked. This made it difficult to show that some people received the support they needed.
“There was limited oversight of the daily records of people's care.” from the report
Management oversight
seriousManagement systems had not identified or corrected all the problems with records, risk assessments and legal requirements. The home had also followed some advice that was not in line with current legislation.
“There were not always accurate up to date records in people's care plans and risk assessments and there was limited oversight of daily records.” from the report
- 01How do you now make sure every person's risk assessment and emergency evacuation plan is accurate and updated after a change in need?
- 02How do you complete and record mental-capacity and best-interest assessments, including for medicines given covertly?
- 03How do you check daily records of food, fluids, personal care and bowel movements, especially for people at risk of weight loss or constipation?
- 04What training and checks are in place to make sure staff protect people's privacy and dignity every time?
- 05What progress has been made on the action plan and the registration conditions mentioned in the inspection report?
This was an unannounced inspection covering all five CQC questions; the report also compared the findings with the previous inspection on 11 December 2017. This explanation was written from the published report of 16 May 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 Sunnycroft Care Home
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- September 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Inadequate
- May 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- September 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016
Registered with the Care Quality Commission on 6 January 2016.
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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