CQC report explained · a residential care home
What the CQC found at Sutton Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2023
Rated Good; inspectors found safe, well-managed care, with some medicines, fire safety and dignity issues to keep under review.
This was an unannounced focused inspection on 21 and 22 September 2023. Inspectors looked at Safe and Well-led after concerns about people's skin care. They spoke with one person, 10 relatives and staff, and reviewed care, medicines, recruitment and management records.
The home was rated Good overall, with Good ratings for Safe and Well-led. Inspectors found that people were protected from abuse, risks were assessed, staffing was sufficient, the home was clean and care records gave staff useful guidance. They found no evidence that the skin-care concern had put people at risk of harm.
There were some issues. Some instructions for 'as needed' medicines did not contain enough detail, some first-floor bedroom fire doors closed quickly, and staff were seen on two occasions not respecting a person's privacy and dignity. The medicines issue was corrected during the inspection, and the fire doors and medicines arrangements will be checked again.
The overall Good rating has remained the same as at the previous inspection, published on 29 July 2019. However, this inspection did not cover all five areas of care, so some ratings were carried forward from that earlier inspection.
Safe staffing
Inspectors found enough suitably skilled and experienced staff. Relatives said staff responded quickly and provided safe care.
“There were enough suitably skilled, trained, and experienced staff to keep people safe.” from the report
Risk management
Care plans included guidance about pressure care, skin care and other health and safety risks. Staff understood how to follow this guidance.
“The registered manager ensured people's pressure care and skin integrity care plans included guidance for staff on how to provide effective care.” from the report
Clean environment
The home and its shared areas were clean and maintained. Inspectors were also assured about infection prevention and control.
“The home, including people's bedrooms, communal areas and shared bathroom and toilets were all clean and well maintained.” from the report
As-needed medicines
needs fixingSome instructions for medicines given when needed did not explain clearly enough when they should be used. The home rewrote the instructions and said the remaining changes had been made, but CQC will check this again.
“We found some of these protocols lacked detail and could lead to the risk of inconsistent administration.” from the report
Bedroom fire doors
needs fixingSome first-floor bedroom fire doors closed quickly. The provider later said the doors had been checked and shut safely, but this will be reviewed at the next inspection.
“some of the bedroom fire doors on the first floor closed quickly which could impact the safety of people and staff.” from the report
Privacy and dignity
minorInspectors saw two occasions when a staff member did not respect a person's privacy and dignity while referring to the support they needed. Management said staff would be reminded about using a dignified approach.
“We did observe a couple of occasions where a staff member did not respect a person's privacy and dignity when referring to an element of support they needed.” from the report
- 01What changes were made to the 'as needed' medicine protocols, and how do you check that staff follow them consistently?
- 02What was the outcome of the checks on the first-floor bedroom fire doors?
- 03How are staff reminded and monitored to protect people's privacy and dignity during personal care?
- 04What was the outcome of the safeguarding incident that was still being discussed with the local authority?
- 05Which ratings were carried forward from the 2019 inspection, and when will the other care areas be reviewed?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection published on 29 July 2019. This explanation was written from the published report of 12 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, July 2019
Sutton Lodge was rated Good; inspectors found kind, personalised care, but medicines records were not always completed properly.
This was a planned, unannounced inspection on 19 June 2019. Inspectors spoke with people living at the home, relatives, staff and the manager. They also checked care records, medicines, staffing, training and quality checks.
The home was rated Good overall and Good in all five areas. Inspectors found enough staff, suitable recruitment checks, clean surroundings and good support with food, health care and activities. People were treated with kindness, respect and dignity.
There were some shortfalls. Medicine records were not completed consistently, and written instructions for medicines given only when needed were not in place. Records did not always show which relatives had legal responsibility for decisions, although the home had started addressing this through a new electronic records system.
The rating remained Good. The previous inspection in 2016 was also Good, although the provider had changed since then.
Person-centred care
Inspectors found that people were at the heart of the service. Staff used knowledge of people's lives and preferences to build relationships and provide individual support.
“The service was exceptional in placing people at the heart of the service and its values.” from the report
Kind and respectful staff
Staff supported people with compassion and respected their dignity, choices and independence.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Meaningful activities
The home offered group and individual activities linked to people's interests and past experiences. This included trips, music, pets and individual wishes.
“People's lives were enhanced because of the responsive approach.” from the report
Good health support
Staff noticed changes in people's health and made timely referrals to health professionals. Care plans included information about specific health needs.
“Records showed that staff were proactive in their approach and made referrals to health professionals in a timely manner.” from the report
Incomplete medicines records
needs fixingSome medicine records were not fully completed. Codes were not always used or explained consistently, and written guidance for medicines given only when needed was missing.
“Some medicine front sheets were not fully completed and codes on medicine administration records were not consistently used or explained.” from the report
Records about decision-making
minorWhere people could not give consent, records did not always show whether a relative had legal responsibility for decisions. The report says the new electronic system was set up to include this information.
“Where people were unable to consent, the provider had not consistently ensured records detailed where relatives had legal responsibility to make decisions on people's behalf.” from the report
- 01What changes have been made to ensure all medicine records are complete and codes are used consistently?
- 02What written guidance is now available for medicines prescribed to be given only when needed?
- 03How does the electronic care record show which relatives have legal responsibility for decisions?
- 04How will you make sure my relative's care plan reflects their history, preferences, communication needs and interests?
This was a planned, unannounced inspection covering the home, the care provided and all five CQC questions; the previous rating was from 2016. This explanation was written from the published report of 27 July 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 Sutton Lodge
2 rated inspections over 4 years: the service has held its Good rating throughout.
- October 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2019GoodSafe: GoodWell-led: Good
- March 2018
Registered with the Care Quality Commission on 29 March 2018.
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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