CQC report explained · a nursing home
What the CQC found at Sutherlands Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2023
Rated Requires Improvement; inspectors found unsafe medicines management and weak oversight, despite improvements in records, communication and activities.
This was a focused inspection. Inspectors visited on 24 and 25 January 2023, with the first day unannounced. They spoke with people, relatives and staff, reviewed care and medicines records, and checked policies, training and quality systems.
The home was still not managing medicines safely. Inspectors found problems with cream storage, medicine records, outdated guidance and medicine residue on equipment. They also found that audits and action plans had not consistently identified or fixed risks.
There were improvements since the previous inspection. Care records were clearer, people were offered choices, activities had improved and relatives said communication was better. Staff were seen to be kind and attentive, but the home remained in breach of regulations 12 and 17.
The overall rating is Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other key questions were not inspected during this visit, so their previous ratings were carried forward.
Clearer care records
Care records had improved since the previous inspection. Daily notes showed the support people received, including fluid, nutrition and repositioning where needed.
“Daily recording evidenced the support people were receiving and sufficient detail was captured to ensure people could be supported consistently.” from the report
Kind staff
Staff were seen speaking with people kindly and spending time with them. People and relatives said staff were approachable and kind.
“Staff were observed talking to people with kindness and compassion and assisting them in a personable way.” from the report
Choice and activities
People were offered choices during the inspection. Activities had improved and people had been supported to access the community.
“Since our last inspection, activities being offered to people had improved, and people had been supported to access the community.” from the report
Infection control
Inspectors were assured about the home's infection prevention arrangements, including the use of protective equipment and managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Better communication
Relatives said communication had improved and that they were kept updated. Meetings and other contact were used to discuss improvements and suggestions.
“Family members confirmed they felt communication had improved and they were kept updated.” from the report
Medicines were not managed safely
seriousInspectors found unsafe storage and incomplete or unreliable records for medicines, especially prescribed creams. They could not always be sure medicines were correctly identified or given as prescribed.
“Topical creams were not stored in a suitable manner.” from the report
Quality checks did not prevent repeat problems
seriousThe home had carried out audits and had an action plan, but these had not consistently found or corrected the risks. Inspectors said governance systems were still not effective enough.
“Systems had not been established to ensure all auditing was meaningful and supported the service to improve their regulatory compliance and to ensure people were safe.” from the report
Some healthcare professional concerns
needs fixingSome healthcare professionals reported delays in seeking support and occasions when their directions were not followed. Others felt improvements were beginning under the new manager.
“Feedback received from healthcare professionals highlighted their concerns in relation to the competency of those employed at times, highlighting delays in seeking support on occasions and not responding as directed by all healthcare professionals.” from the report
Capacity assessments needed more detail
needs fixingPeople were observed being offered choices and legal authorisations were in place where needed. However, inspectors said capacity assessments needed further review and expansion.
“Mental Capacity Assessments did require further review to ensure these records were robust and detailed all required information.” from the report
- 01What has been done to make sure prescribed creams are correctly labelled, stored, temperature-checked and recorded?
- 02How do you now check that medicines are given as prescribed and that medicine equipment is clean?
- 03What changes have been made to ensure audits identify and fix risks rather than marking unfinished actions as complete?
- 04How are healthcare professionals' instructions recorded and checked to make sure they are followed without delay?
- 05Has the manager's application to become registered been completed, and how is leadership being kept stable?
This was a focused inspection of Safe and Well-led only; ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 9 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, July 2022
Requires Improvement; inspectors found risks with falls, care records, medicines and management oversight.
This was a focused inspection on 14 and 15 June 2022. Three inspectors and an Expert by Experience visited the home, spoke with people, relatives and staff, and reviewed care records, medicine records, staff records and other documents.
The home was not always safe. Referrals after repeated falls were not always made. Care plans did not always explain how to keep people safe. Medicines were not consistently managed as prescribed, and some staff had not completed training for people's health needs.
The home was not well-led. Audits had not picked up important problems, there was no registered manager in post, and families said communication about changes was poor. The provider had started an improvement plan, but CQC said it would take time to become fully established.
The overall rating fell from Good at the previous inspection to Requires Improvement. Only Safe and Well-led were inspected at this visit. The other question ratings were carried over from the previous inspection.
Safe recruitment
The home carried out checks on staff backgrounds and suitability before employment.
“Staff were safely recruited, and checks were made on their character from previous employers and on their suitability through the Disclosure and Barring Service (DBS).” from the report
Mental capacity safeguards
Inspectors found that the home was working within the principles of the Mental Capacity Act. Legal authorisations and a record of applications were in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Medicine administration observed
Although medicine systems had serious gaps, inspectors observed staff giving medicines safely and respectfully, with records made.
“We observed staff administer medicines to people. They carried this out safely and supported people with dignity.” from the report
Action plan started
The provider had begun an action plan before the inspection. Some new care planning and falls processes had been introduced, although they still needed to become established.
“The provider and operations manager had implemented an action plan prior to our inspection to make improvements to the service.” from the report
Working with health professionals
The home sought advice from health professionals, including GPs, about medicines and people's health needs.
“The service engaged with healthcare professionals to seek advice, resolve issues and review people's medicines and health care needs, such as people's GP's.” from the report
Falls and care planning
seriousRepeated falls did not always lead to referrals to specialist falls services. Care plans and daily records lacked enough detail to guide staff safely and consistently.
“Appropriate referrals had not always been made when a person experienced multiple falls, placing them at risk of injury due to a lack of appropriate action being taken by the provider.” from the report
Medicine safety
seriousInspectors found medicine errors, problems with medicated patches and gaps in information about medicines given when needed. Records and assessments for covert medicines were also incomplete.
“Medicines were not always managed safely, Medicine errors identified during this inspection had not been identified by the staff administering the medications and was identified by a visiting healthcare professional.” from the report
Training gaps
needs fixingNot all staff had the training needed for people's individual health conditions. No staff had epilepsy training at the time of the inspection, despite people living there having epilepsy.
“For example, we identified that no staff had epilepsy training at the time of the inspection, but there were people living at the service with this known healthcare need.” from the report
Weak management oversight
seriousAudits did not reliably identify problems in care plans, daily records or medicine records. Several management changes had made it difficult to establish consistent leadership.
“The service had experienced numerous management changes within a short period. This includes two operations managers leaving, the registered manager and a home manager in quick succession.” from the report
Communication with families
needs fixingSome families felt they were not kept informed about falls, management changes or what was happening in the home.
“Families we spoke to did not feel well engaged by the service or kept updated on changes with management.” from the report
- 01What changes have been completed to make sure every repeated fall is referred to the specialist falls service?
- 02How are medicines, including medicated patches, as-needed medicines and covert medicines, now checked and recorded?
- 03Which care plans have been rewritten, and how do you check that daily records contain enough detail for safe care?
- 04Who is currently managing the home, and when will a registered manager be in post?
- 05How do you check that staff have completed training for residents' specific health needs, including epilepsy?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried over from the previous inspection. This explanation was written from the published report of 21 July 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 Sutherlands Nursing Home
8 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- January 2021Goodstayed GoodSafe: GoodWell-led: Good
- October 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- September 2017Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 5 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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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.