CQC report explained · a residential care home
What the CQC found at Sutton House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Two incidents involving one person hitting another were not raised as safeguarding concerns. Risk assessments and behaviour support plans were not always updated after incidents or changes in people's needs.
- Effective?
- Good
- People's needs were assessed and staff had relevant training. People were supported with food, healthcare and decision-making, including under the Mental Capacity Act.
- Caring?
- Good
- Inspectors saw kind, respectful and patient interactions. People were involved in decisions and supported to maintain relationships and independence.
- Responsive?
- Good
- People had personalised activities and communication plans. They were supported to follow their interests, attend courses, travel and maintain contact with relatives.
- Well-led?
- Requires improvement
- The provider had quality monitoring systems, but these were not always used effectively. Incident analysis, safeguarding oversight and the gathering of relatives' views were not yet fully effective.
What inspectors found, October 2023
Rated Requires Improvement; inspectors found kind, personalised care, but concerns about safeguarding, risk records and management oversight.
Inspectors visited on 2 and 3 August 2023. The first day was unannounced. They met all five people living in the home, spoke with staff and relatives, and checked care, medicine, recruitment and management records.
People were treated with kindness and supported to make choices, stay in touch with relatives and take part in activities at home and in the community. Staff had suitable training, medicines were managed safely, and people's health needs were supported.
However, some safeguarding concerns had not been reported. Risk assessments and behaviour support plans were not always updated after incidents or changes in people's needs. The systems used by managers to check quality and learn from incidents were not always effective.
The overall rating changed from Good at the previous inspection in 2017 to Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led were rated Requires Improvement.
Kind and respectful care
People received compassionate support. Staff respected privacy, dignity and individual preferences.
“People received kind and compassionate care from staff.” from the report
Choice and independence
People were supported to make choices, try new experiences and develop independence at home and in the community.
“People had the opportunity to try new experiences, develop new skills and gain independence.” from the report
Activities and community life
People took part in activities suited to their interests, including trips, college courses, holidays and visits to local facilities.
“People were supported to do things they enjoyed doing at home and in the community.” from the report
Medicines and staffing
Inspectors found that medicines were given, recorded and stored safely. There were enough staff during the inspection, with recruitment checks completed.
“People received their medicines safely and on time.” from the report
Safeguarding was not always reported
seriousSome incidents that put people at risk were not recognised or reported as safeguarding concerns. An unplanned restraint incident was also not reviewed or shared with the local authority.
“We found no evidence that people had been harmed however, not recognising and raising safeguarding concerns placed people at an increased risk of harm.” from the report
Risk records were not consistently updated
seriousBehaviour support plans and risk assessments did not always reflect what had happened or changes in people's health and mobility needs. Emergency evacuation plans also needed more detail.
“Risk assessments were not always updated when there were changes in people's needs.” from the report
Management checks were not effective enough
seriousThe provider's systems did not consistently investigate incidents, identify learning or update people's records. Oversight of safeguarding was also not always effective.
“The provider's quality assurance systems and processes were not always effective.” from the report
Some environmental improvements were needed
needs fixingA shower chair had rust and was replaced during the inspection. A laundry arrangement and a chipped kitchen surface also needed attention, and some bathroom changes were still being considered.
“Some reasonable adjustments were needed to bathroom facilities to ensure people's changing needs continue to be met.” from the report
- 01What action have you taken to make sure every safeguarding concern is recognised, reported and reviewed?
- 02How do you now make sure behaviour support plans and risk assessments are updated after incidents or changes in health and mobility?
- 03What evidence can you show that your quality checks identify learning from incidents and prevent them happening again?
- 04Have the recommended bathroom changes and extra information in emergency evacuation plans been completed?
- 05How are you now collecting and using the views of relatives and professionals?
This was a full inspection covering all five CQC questions, including the premises and care provided; infection prevention and control was also checked as part of Safe. This explanation was written from the published report of 28 October 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, September 2017
Rated Good; inspectors found safe, kind and personalised care, with effective management checks in place.
Inspectors visited without notice on 23 August 2017 and returned on 25 August to finish the inspection. They met four people, observed care, spoke with relatives and staff, and checked care plans, medicines records, recruitment files, incident records and quality checks.
The home supported five people with learning disabilities and behaviours that challenge others. Inspectors found that staff understood people's risks, supported medicines safely, respected choices and privacy, and provided care suited to individual needs.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The home was still rated Good, matching its previous rating. A registered manager was now in place, and the management team had introduced further checks and an action plan.
Understanding risks
Staff knew the risks affecting people and the support needed to reduce them. Staffing could be increased when people needed extra support for activities.
“Staff we spoke with knew the type and level of assistance each person required.” from the report
Respectful care
Staff gave people time to communicate, asked permission before providing support and respected private space. They also encouraged independence with everyday tasks.
“Throughout our inspection we saw that staff asked people's permission before supporting them and that staff recognised the importance of not intruding into people's private space.” from the report
Individual support
Staff understood people's routines, preferences and ways of communicating. Support plans and staff training were adapted to individual needs.
“It was evident that staff had a good insight into people's personal routines and preferences.” from the report
Management oversight
The management team used audits, visits, feedback and staff meetings to check care and address any shortfalls. There was also an action plan for further development.
“The care people received was checked and updated regularly by the management team.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you make sure staff understand my relative's individual risks and the support they need?
- 02How do staff recognise and respond to my relative's preferred ways of communicating choices?
- 03What further staff supervision and knowledge checks are being introduced for medicines and the Mental Capacity Act?
- 04How will you involve our family in meetings and decisions about changing care needs?
- 05How are quality checks and the action plan used to improve care at the home?
This was an unannounced inspection covering all five key questions; inspectors returned on 25 August 2017 to finish it. This explanation was written from the published report of 23 September 2017 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 House
4 rated inspections over 9 years: the service has held its Requires improvement rating throughout.
- October 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2015Requires improvementSafe: Requires improvementEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- February 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 18 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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