CQC report explained · a residential care home
What the CQC found at Sutton Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2022
Sutton Court is rated Requires Improvement; inspectors found clear progress after an earlier Inadequate rating and Special Measures, but important care plans and systems were still unfinished.
This was an unannounced, planned comprehensive inspection on 10 and 11 January 2022. Inspectors spoke with eight people, three relatives, five staff and two visiting professionals. They observed care and reviewed care, medicine, staffing and management records.
The home had made substantial improvements since its last inspection in June 2021. People were doing more everyday activities, following their interests and making more choices. Staff were kinder and more knowledgeable about learning disabilities, autism, safeguarding and positive behaviour support.
However, all five areas were rated Requires Improvement. Inspectors found that safety checks, sensory information, communication guidance, goals and staff learning were not yet consistently recorded or embedded. The home was no longer in breach of regulations and was no longer in Special Measures.
Requires Improvement means some parts of care were not always safe, effective, caring, responsive or well-led. Inspectors said there was limited assurance about safety and that inconsistent management and leadership did not always support high-quality, person-centred care.
More meaningful activities
People were taking part in ordinary household tasks, hobbies and leisure activities. This was a clear improvement from the previous inspection, when people had little to do at home.
“At the last inspection people had little to do when at home, now they had more to occupy and interest them.” from the report
Greater independence and choice
People were supported to make more decisions and take part in cooking, cleaning and other daily tasks. Staff were beginning to use active support to build confidence and independence.
“People had the opportunity to try new experiences, develop new skills and gain independence.” from the report
Kind and respectful care
Inspectors observed staff treating people with warmth, privacy and dignity. People were also supported to stay in contact with relatives and other important people.
“Staff members showed warmth and respect when interacting with people.” from the report
Improved safeguarding and incident learning
Staff understood how to recognise and report abuse. Managers were analysing incidents, taking action and sharing lessons to reduce the chance of problems happening again.
“Staff were now able to demonstrate they understood abuse and restrictive practice.” from the report
Safety guidance was not always recorded
seriousSome safety instructions, including guidance about going out independently and sensory needs, relied on staff knowing people well. This could create risks when new or agency staff provided support.
“The guidance for this had not been recorded which meant the provider could not be assured all staff understood the person's support plan or its potential safety implication.” from the report
Care plans lacked goals and detailed teaching steps
needs fixingPlans did not consistently record people's aspirations or explain the steps staff should use to help them develop skills. This could make support inconsistent.
“Support plans did not contain people's goals and aspirations or detailed guidance for staff to work towards them.” from the report
Sensory and communication support needed more work
needs fixingStaff knowledge had improved, but information about sensory and communication needs was not always written in support plans. Inspectors said staff needed more training and consistency.
“Staff were not fully aware of individual's sensory perception and processing difficulties.” from the report
Quality system was not fully tested
needs fixingA new quality assurance system had been introduced shortly before the inspection. Inspectors could not yet see that it was effective because it had not been in place long enough.
“The new quality assurance system had not yet been tested to demonstrate its effectiveness and needed time to develop and embed.” from the report
- 01How will you record each person's sensory needs and communication methods so agency and new staff can follow them?
- 02What are each person's goals and longer-term aspirations, and how will staff support them step by step?
- 03What weekly checks are now being completed to identify damaged furniture, bedding and other safety problems?
- 04How will you test and show that the new quality assurance system is working effectively?
- 05What further training will staff receive about autism, sensory needs, communication tools and positive behaviour support?
This was an unannounced comprehensive inspection covering all five key questions, including infection prevention and control under Safe, and checking improvements after the June 2021 inspection. This explanation was written from the published report of 5 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, November 2021
Rated Inadequate and placed in special measures; inspectors found serious problems with safety, medicines, safeguarding and leadership.
This was an unannounced inspection over three days. Inspectors spoke with people, staff, relatives and professionals. They observed care and checked care plans, medicine records, training information and management records.
The home was not always safe. Staff did not consistently recognise or report abuse, medicines were not managed safely, some fire risks had not been dealt with and staff lacked important training. Care was often kind, but people's dignity, choices, communication and independence were not consistently supported.
The overall rating fell from Good at the previous inspection to Inadequate. Safe and well-led were rated Inadequate. Effective, caring and responsive were rated Requires Improvement. The home was placed in special measures, with further monitoring and a planned reinspection.
Safe recruitment
The provider completed appropriate checks before staff started work.
“The provider carried out appropriate checks before they started working at the service.” from the report
Meals and choice
People enjoyed the food and were offered alternatives when they did not want the group meal.
“People were offered alternatives if they did not like the meal the group had chosen.” from the report
Health support
People generally had good access to physical healthcare. Staff also helped some people feel more confident about attending appointments.
“People had good access to physical healthcare and were generally supported to live healthier lives.” from the report
Kind interactions
Inspectors saw that most staff interactions with people were kind and friendly.
“We observed the majority of staff interactions with people were kind and friendly.” from the report
Advocacy and relationships
People could access independent advocacy, and staff supported them to keep in touch with important people.
“People had access to independent advocacy for support with specific issues.” from the report
Safeguarding failures
seriousStaff did not always recognise or report possible abuse. Inspectors had to remind the manager to report an incident to the local safeguarding team.
“The original safeguarding concern that had triggered this inspection had not been reported by staff who had witnessed it.” from the report
Medicine errors
seriousOne person's new medicine was delayed for 10 days. Stock discrepancies affecting five people meant some people might not have received their prescribed doses.
“This meant that people did not always get their correct prescribed doses.” from the report
Fire and other risks
seriousFire doors were wedged open and required safety work had not been completed. Some emergency evacuation arrangements and environmental risks had not been properly assessed.
“Risks to people from fire were not adequately assessed or mitigated.” from the report
Staff training
seriousHalf the staff team had not received training to support people with learning disabilities or autistic people. Staff also did not consistently use people's communication methods.
“Half of the staff team had not received any training to support people with a learning disability or autistic people.” from the report
Limited person-centred support
needs fixingCare plans did not consistently include people's goals, interests or ways to improve their quality of life. Activities were limited and often depended on staffing and transport.
“People's plans did not contain goals they could work towards to support independence, self-worth or aspirations they might have.” from the report
Weak oversight
seriousManagement systems did not reliably identify problems or learn from incidents. Records and monitoring were sometimes poor.
“The lack of robust quality assurance meant people were at risk of receiving poor quality care.” from the report
- 01What changes have been made to prevent medicine delays, stock discrepancies and recording errors?
- 02How are safeguarding concerns and restrictive practices now recognised, recorded and reported?
- 03What training has every staff member completed on learning disability, autism and people's communication needs?
- 04How have fire safety checks, evacuation plans and other environmental risk assessments been completed?
- 05What individual activities, goals and independence plans are now in place for each person?
The inspection was initially targeted because of risk, then expanded into a comprehensive inspection covering all five key questions; the previous ratings were Good at the inspection published on 31 January 2019. This explanation was written from the published report of 16 November 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 Sutton Court
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- March 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2021Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 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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