We carried out a review of the data available to us about Sutton Village Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Sutton Village Care Home, you can give feedback on this service.
People’s experience of using this service: Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question Safe and Well-Led to at least good. At this inspection, we found improvements had been made and the provider was now compliant with the regulation. Action had been taken to ensure medicines were managed safely and systems to assess and monitor the safety and quality of the service were effective.
Systems were in place to maintain people’s safety and protect them from abuse. Risks were identified, appropriate control measures were implemented, and the safety and cleanliness of the environment was maintained. Systems were in place to recruit staff safely.
People were supported with good nutrition and could access appropriate healthcare services. Staff were equipped with relevant skills.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
People were supported by staff who were kind and caring and were aware of how to promote people’s privacy and dignity.
Staff were responsive to people’s needs and provided support in line with their preferences. People had care plans in place which provided information to staff about their needs. They were involved in planning and reviewing their care and support. An activities coordinator supported people to engage in their social and leisure interests.
People were able to raise any concerns and felt these would be addressed. They felt listened to and their feedback was sought. People and staff felt the registered manager was accessible and approachable.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection: Requires Improvement (report published 23 May 2018).
Why we inspected: This was a planned inspection based on the previous rating.
Follow up: We will continue to monitor this service and inspect in line with our re-inspection schedule or sooner if we receive information of concern.
The service had a registered manager. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At the last inspection on 30 March 2017 and 04 April 2017, we found the service requires improvement.
During this inspection, we found that although the service had taken steps to make improvements, which we recommended during the last inspection, the service continued to requires improvement.
At the last inspection, the service was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to ensure systems and process were established and operated effectively to assess, monitor, mitigate risks and improve the quality and safety of the service. We asked the provider to complete an action plan to show what they would do and by when to improve the key question well-led to at least good. The registered manager completed an action plan showing how they would meet Regulation 17 of the Health and Social Care Act 2008, to improve the governance of the service.
During this inspection, we saw that the registered manager and provider had put systems in place and improvements had been made so there was no longer a breach of Regulation 17. However, some further improvement was still required.
We found medications were not always administered as prescribed. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Two people had not received their pain patches which could have put them at risk of possible harm. Guidance to support staff to administer specific medication did not always include sufficient information for staff to administer these as prescribed. You can see what action we told the provider to take at the back of the full version of the report.
Risk assessments were in place; however, risks were not always appropriately reviewed and updated when people’s needs changed. This meant people could have been at risk of potential harm. For example, we saw for one person action had been taken to protect them from the risk of falling. However, their risk assessment had not been updated after they had experienced falls, to ensure staff were aware of additional measures that were needed to prevent further falls.
Staff were recruited appropriately and there was sufficient staff. However, they were not always deployed appropriately at meal times. This meant some people were not supported to eat their meals at the same time as everyone else and had to wait to be supported.
Staff had received safeguarding training and were knowledgeable about safeguarding and how to report concerns to protect people from harm.
The service was clean and infection and prevention control procedures were in place to prevent the spread of infection.
People were supported by staff who had received relevant training and were suitably qualified for their role, to meet people’s needs.
Consent was gained before care and support was delivered and the principles of the Mental Capacity Act (MCA) were followed within the service.
CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager was aware of their responsibility in relation to DoLS. When people were unable to consent to their care and staying at the service the registered manager had applied for DoLS as necessary.
People were supported to meet their nutritional needs and maintain a balanced diet. People were offered choice at meal times and if people’s choices were not available, staff would seek to accommodate their preferences.
People were cared for by staff who were kind and respectful and treated people with dignity. People were supported to maintain their independence where possible.
People’s healthcare needs were responded to and when concerns were identified, relevant professionals were contacted for their advice and guidance.
Care plans were in place for people who used the service so staff knew how to meet their needs; These were detailed and person-centred. However, some of the care plans we saw were not updated as people's needs changed. The registered manager told us they were aware of which ones required updating and would ensure this was completed.
People were supported to access social and leisure activities and maintain relationships with family and friends. The service had developed links with the local community and worked in partnership with other professionals and organisations.
People were supported until the end of their life. The registered manager had developed a template for recording people’s preferences and wishes about the support they may want at the end of their life. However, these had not been completed so people’s wishes were not recorded. The registered manager told us these would be completed, so people had the opportunity to express their wishes for future care if they wanted to.
Records showed very few complaints were received. A complaints policy was in place and people told us they knew how to make a complaint if needed.
The registered manager understood and fulfilled their responsibilities to report accidents and incidents, as well as other notifiable events to the Care Quality Commission as required.
The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At the last comprehensive inspection on 2 December 2014 and 16 January 2015, we rated the service as Good overall.
During this inspection we found that the registered provider had failed to establish and operate effective governance systems. There was a clear lack of auditing and governance systems in place to ensure shortfalls were highlighted in a timely way.
Staff did not receive an annual appraisal in 2016 and there was no system in place to ensure they received supervision meetings on a regular of consistent basis.
The registered manager was aware of their responsibility in relation to the Deprivation of Liberty Safeguards but had failed to submit applications for 21 people who used the service.
Care plans had been developed to meet the assessed needs of the people who used the service. However, some of the care plans we saw were not updated as people’s needs changed or developed. We also found that healthcare professional’s advice and guidance was not always incorporated in to people’s care plans.
Checks of equipment used within the service were completed in line with manufacture guidelines but the service’s periodical electrical test had been allowed to expire. This placed people who used the service at risk.
People who used the service were protected from abuse and avoidable harm by staff who had been trained to recognise the signs of potential abuse and knew what actions to take if they suspected abuse had occurred. Staff had been recruited safely and were deployed in suitable numbers to meet the assessed needs of the people who used the service. People’s medicines were administered as prescribed.
People were supported by staff who had completed a range of training and nationally recognised qualifications in health and social care. Consent was gained before care and support was delivered and the principles of the Mental Capacity Act were followed within the service. People were supported to eat a balanced diet of their choosing. When concerns were identified, relevant professionals were contacted for their advice and guidance.
People told us they were supported by kind and caring staff who knew their preferences for how care and support should be delivered. During observations it was clear caring relationships had been developed between the people who used the service and staff. People’s privacy and dignity was respected by staff who understood the need to treat sensitive information confidentially. During the inspection we had to remind the registered manager to ensure care records could not be accessed by unauthorised people.
People were involved with the initial and on-going planning of their care. Their levels of independence and individual strengths and abilities were recorded. People were encouraged to maintain relationships with important people in their lives and to follow their hobbies and interests. The registered provider displayed their complaints policy within the service to ensure it was accessible to people. Records showed very few complaints were received by the service.
The registered manager understood and fulfilled their responsibilities to report accidents and incidents as well as other notifiable events to the Care Quality Commission as required. The service had developed links with the local community.
Sutton Village Care Home is situated close to local facilities and bus routes into Hull. The main building provides accommodation and personal care for up to 23 older people, some of whom live with dementia. The extension has 10 single ensuite bedrooms. Both parts of the service have a range of communal rooms and bathrooms.
The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
This inspection was unannounced and took place over two days. The previous inspection of the service took place on 17 December 2013 and was found to be compliant with the regulations inspected.
People who used the service told us they felt safe and that there were enough staff on duty to meet people’s needs. Comments included, “Yes, I am safe”, “I am extremely well looked after”, “The manager is excellent” and “Of course I feel safe.”
Staff had received training in safeguarding vulnerable adults from abuse and the registered provider had policies and procedures in place to protect people from harm or abuse.
Medicines were stored securely and administered safely. Records showed people received their medicines on time and in accordance with their prescription.
The service was kept very clean. The building was well maintained and furnished.
Staff told us they had been recruited into their roles safely. We saw appropriate pre-employment checks were undertaken prior to people commencing their employment with the service.
Staff involved people in choices about their daily living and treated them with compassion, kindness, and respect. People told us, “The staff are good here”, “Yes, I think the staff are trained”. People were supported by staff to maintain their privacy, dignity and independence. Everyone looked clean and well-cared for.
The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and staff followed the Mental Capacity Act 2005 for people who lacked capacity to make decisions for themselves. These safeguards provide a legal framework to ensure people are only deprived of their liberty when there is no other way to care for them or to safely provide treatment.
The food looked appetising. We saw some people were offered assistance with cutting food up and were given plate guards and adapted cutlery which assisted their independence. People were offered a choice of drink at the table and the choice of a different meal if they did not like the one they had chosen. People told us, “I like the dinners; they are really filling” and “Yes, we get a choice of meals and I like them.”
Care plans were written around the individual needs and wishes of people who used the service. We saw care plans contained detailed information on people’s health needs and their preferences.
People who used the service knew how to make a complaint. They told us they were able to express their views at any time and that they were listened to.
Leadership and management of the service was good. There were systems in place to effectively monitor the quality of the service and staff felt well trained and supported.
People had their needs assessed and their care planned so that staff had guidance in how to care for them. People told us staff respected their privacy and dignity and ensured their health needs were met. Comments included, 'I am ever so well looked after' and 'If they thought I wasn't well they would call the doctor.'
We found people's medicines were managed well so they received them on time and didn't run out of them. People told us they received their medicines on time.
Although staff were busy, we found there were enough staff to support the current needs of people who used the service. People told us staff were kind to them and comments included, 'When I ring the bell it doesn't take them long' and 'I am very comfortable here.'
We found most records were accurate, up to date and easy to locate. The manager was addressing an issue with the environmental risk assessment and personal emergency evacuation plans.
We found the home was well maintained, warm, clean and tidy. Comments included, "I love it here. I couldn't imagine being more settled anywhere else", "I have a lovely room with high ceilings and windows" and "It's always clean and tidy when I visit."
We found that staff received appropriate training, supervision and support for their role.
We found that quality was monitored by audits of the service and questionnaires to people to find out their views.
People who used the service told us they felt able to complain and named specific staff members they would speak to if they had any complaints or concerns. Comments included, 'Yes I would feel able to complain if necessary' and 'If you are not happy you tell the manager or higher up.'
People told us they could make choices such as where to spend their time during the day, which activities to participate in, what time to rise and retire and what to eat for each meal. They also told us that staff were kind and treated them with respect. Comments included, 'I like it here very much. I like to stay in my room, I like to be where it's quiet' and 'They always knock on doors.'
People spoken with said they were able to see their GP when required. They told us they were well looked after.
People spoken with told us the staff were friendly and kind and come quickly when they rang the bell for assistance. Comments included, 'The staff come quickly ' they are here in a minute' and 'They are kind to you and don't shout at you like other places.'