CQC report explained · a nursing home
What the CQC found at Sutton in the Elms
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that infection risks were being managed, including PPE, testing, visits, admissions, cleaning and outbreak management. The provider also said it had measures to manage COVID-19-related staffing pressures.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, March 2022
Inspected but not rated; inspectors were assured that infection prevention and control arrangements were in place.
This was an unannounced, targeted inspection on 20 January 2022. It focused on infection prevention and control during the COVID-19 pandemic, and on whether staffing pressures were affecting care.
Inspectors were assured that the home used PPE safely, supported testing, managed visits, admitted people safely and kept its infection control policy up to date. They also found measures to manage COVID-19-related staff pressures.
The home was inspected but not rated. This means the report does not give an overall quality rating or a rated judgement for Safe.
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections, including safe PPE use, testing and outbreak management.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Support for family contact
During lockdown, staff kept families informed by making regular phone calls and reassuring them about people's wellbeing.
“Managers and staff understood the importance of keeping in contact with people's family/friends during period of lockdown due to Covid-19.” from the report
Visits and cleanliness
The home had designated staff on each shift to oversee visits, keep PPE stations stocked and help keep high-risk areas clean.
“The service had designated 'Covid Marshals' on each shift. They oversaw visits, ensured PPE (personal protective equipment) stations were stocked, and kept high-risk areas of the premises clean.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing staffing pressures, and have they affected people's care?
- 02How do you make sure PPE stations are stocked and PPE is used safely?
- 03How do you currently manage visits and reduce the risk of infection spreading?
- 04How do you test people using the service and staff when needed?
- 05How do you safely admit new people and manage any infection outbreaks?
This was a targeted inspection of infection prevention and control and staffing pressures; the service was inspected but not rated and the other four key questions were not assessed. This explanation was written from the published report of 16 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, August 2021
Rated Good; inspectors found kind, personalised care and strong management, with a few medicines and maintenance issues to monitor.
This was the home’s first comprehensive inspection. It was unannounced and took place on 17 June 2021. Inspectors spoke with people living there, relatives and staff, and reviewed care, medicines, management and infection control records.
The overall rating was Good. All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found the home was well staffed, clean and spacious, and that people received personalised care from caring staff.
There were some minor shortfalls. A few medicines records lacked staff signatures, one lacked a photograph, and instructions for some time-specific medicines did not state the exact times. Some handrails were hard to see and part of a patio needed maintenance. Managers said these issues would be addressed.
Kind, individual care
Inspectors found that staff knew people well and provided care based on their individual needs, preferences and choices.
“People using the service received person-centred care from a skilled, caring and well-led staff team.” from the report
Staffing and responsiveness
The home was well staffed, and people’s needs were met promptly. The home did not use agency staff.
“The service was well-staffed, and people's needs were promptly met.” from the report
Activities and quality of life
People had access to a wide range of group and one-to-one activities, including events designed to involve people with different mobility levels.
“The service's activities co-ordinators provided a programme of one-to-one and group activities and events.” from the report
Learning and improvement
Managers used audits, feedback and meetings with relatives to make changes. The report says care plans and risk assessments improved after a new audit system was introduced.
“To address this, the provider introduced a more effective audit system where any shortfalls were identified and relayed to the registered manager to address.” from the report
Health and wellbeing support
The home worked with GPs, nurses, therapists and other professionals to meet people’s healthcare, nutritional and end of life needs.
“Staff worked closely with these professionals and followed their advice and suggestions.” from the report
Medicines records
needs fixingA few medicines records were missing staff signatures, and one did not include a photograph. Some records also lacked the exact times for time-specific medicines. Managers acted promptly after inspectors raised this.
“Some people were on 'time specific' medicines but medicines records didn't always state the exact time these should be given” from the report
Patio maintenance
needs fixingOne enclosed patio needed weeding and had uneven paving stones, which inspectors said could create a trip risk.
“one of the enclosed patio areas needed weeding and some of the paving stones were uneven which could result in a person tripping.” from the report
Visibility of handrails
minorSome corridor handrails were painted a similar colour to the walls, which could make them harder for a visually impaired person to identify.
“In some corridors the handrails were painted a similar colour to the walls which could make it difficult for a visually impaired person to identify them.” from the report
- 01Have all missing medicines signatures and photographs been corrected, and how do you check this now?
- 02How are the exact times for time-specific medicines recorded and checked?
- 03Has the uneven paving in the enclosed patio been repaired?
- 04What has been done to make corridor handrails easier for visually impaired people to see?
- 05How have the management and staff changes affected communication with families and the quality of care?
This was the first comprehensive inspection of the newly registered home and covered all five CQC questions, including infection prevention and control. This explanation was written from the published report of 5 August 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 in the Elms
4 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- August 2021GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- December 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2020
Registered with the Care Quality Commission on 15 January 2020.
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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