CQC report explained · a nursing home
What the CQC found at Sutton Rose Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People did not always receive medicines as prescribed. Records for medicines, pain patches, skin damage and dehydration were not always complete, although staffing, infection control and safeguarding arrangements were described positively.
- Effective?
- Requires improvement
- Staff had training and people had access to health professionals and suitable food. However, not all staff knew about restrictions under DoLS, least restrictive decisions were not recorded robustly, and records did not always show that PEG care was provided as expected.
- Caring?
- Requires improvement
- Inspectors saw kind and patient interactions, and people said staff respected their privacy and dignity. However, bedroom CCTV had not been fully assessed for privacy, and footage had been shared with a relative without a recorded rationale.
- Responsive?
- Good
- People had personalised care plans, activities and support to keep in contact with family and friends. Complaints were handled through the provider's process, although involvement in care plan reviews was not always recorded.
- Well-led?
- Requires improvement
- Managers were open to feedback and had plans to improve. However, audits did not identify some medicine and record-keeping problems, and there was no effective system to oversee CCTV use or some care monitoring records.
What inspectors found, August 2021
Requires Improvement; inspectors found kind care and good activities, but medicines, records, privacy and management systems needed improvement.
This was the first inspection since the home registered with CQC. Inspectors visited on 7 and 8 July 2021. They spoke with people living there, relatives and staff, observed care, and checked care, medicines, staffing and management records.
The home was clean and well maintained. Staff were available and inspectors saw kind interactions. People generally felt safe, liked the food, had activities and were supported to keep in touch with family. The responsive rating was Good.
There were important shortfalls. Some people did not receive medicines as prescribed. Records about care, skin damage, dehydration and PEG care were not always complete. CCTV in bedrooms had not been properly assessed for privacy. The systems used by managers to find and correct these problems were not effective.
Kind staff interactions
Inspectors saw staff treating people with patience and compassion. Staff explained the support they were giving and reassured people who were distressed.
“We observed kind and caring interactions between staff and people.” from the report
Food and support at mealtimes
People were offered drinks, snacks and a choice of food. Staff knew about specific dietary needs and provided support at lunchtime.
“People were positive about the food provided and told us they received a choice.” from the report
Activities and family contact
People could choose whether to join activities and were supported to maintain contact with relatives and friends, including during COVID-19 restrictions.
“People told us they had been supported to maintain contact with family or friends during COVID-19 restrictions.” from the report
Staff availability
Inspectors found staff visible around the home and people needing help were supported promptly. Most people and relatives said staffing was sufficient.
“There were enough staff to meet people's needs.” from the report
Medicines were not always safe
seriousTwo people had missed some prescribed medicines for several days. Medicine records also had gaps, and other safe medicine procedures were not always followed.
“People did not always receive their medicines as prescribed.” from the report
Care records were inconsistent
needs fixingRecords did not always show that people received care planned for skin damage, dehydration or PEG care. There was no audit system for some fluid and repositioning charts.
“Monitoring records to support people at risk of skin damage and dehydration were inconsistent.” from the report
Bedroom CCTV and privacy
seriousCCTV had been installed in bedrooms without a full privacy assessment or a data protection impact assessment. The report also found that footage had been shared without a recorded rationale.
“Full consideration had not been given to ensure people's privacy in their bedroom had been fully considered.” from the report
Management checks missed problems
seriousThe provider's audits did not identify some medicine, record-keeping and CCTV issues. This led to a breach of the good governance regulation.
“The provider's governance and quality assurance systems and processes were not sufficiently robust or effective.” from the report
- 01What changes have been made to ensure people receive every prescribed medicine, and how are missed doses escalated?
- 02How do you now check fluid, repositioning, skin damage and PEG care records for accuracy and completeness?
- 03Has CCTV in bedrooms remained turned off, and what privacy and legal assessment will be completed before any decision to use it again?
- 04What action has been taken in response to the two breached regulations, and what evidence can you show of improvement?
- 05How are people and relatives involved in care plan reviews and kept informed about their family member's wellbeing?
This was the first comprehensive inspection of the newly registered home and covered all five key questions, including infection prevention and control arrangements. This explanation was written from the published report of 24 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 Rose Care Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- August 2021Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- December 2020
Registered with the Care Quality Commission on 7 December 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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