Sutherlands Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service remained in breach of the legal regulation in relation to people’s safe care and treatment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The manager reviewed incidents and accidents to identify any themes and trends to inform risk management.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. We saw evidence of appropriate referrals, for example, to speech and language therapists and dietitians where this was required.

People were protected from the risk of abuse and improper treatment. The provider shared concerns quickly and appropriately. Referrals to other agencies were made appropriately. Staff received regular safeguarding training. Staff understood their responsibilities in relation to keeping people safe and felt confident to raise these with the manager. One staff member said, “I know what to look for, for example, unexplained bruising. If I had any concerns I would go straight to the manager.”

The provider did not always work well with people to understand and manage risks. For example, we reviewed evacuation plans for people in the service and found the staffing levels at night had not been tested to ensure people could be evacuated safely in the event of a fire. We notified the local fire authority of our concerns.

The provider did not always detect and control potential risks in the service. They did not always make sure equipment supported the delivery of safe care. For example, where people used airflow pressure mattresses to reduce the risk of skin breakdown, there were no records of what setting these should be set to. Daily records stated these had been checked, despite there being no settings for staff to know what they were to check. An electrical safety report in 2022 had identified various actions but these had not been completed. We raised this with the provider who told us they would source an electrician to address the outstanding actions. Other health and safety checks were in place and action was taken when issues were identified. After our inspection visit, the provider told us they had implemented more robust systems in relation to airflow mattresses. We will check for improvements during our next inspection.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. For example, all staff were required to complete The Care Certificate, nationally recognised standards to support staff to gain skill and knowledge in care. However, we found only the e-learning element had been completed and there had been no knowledge checks, as is required to complete the course. We found improvements were needed to how the provider evidenced nurses were confirmed to be competent with aspects of their role such as wound care and intramuscular injections. This meant the provider could not effectively evidence that nurses could safely meet people's nursing needs. Although during our visits we observed there were enough staff to meet people's needs, people and staff told us sickness could not always be covered and this meant people could have to wait longer for support. For example, a person said, "There are occasional shortages usually caused by staff sickness. You know they're short as you see them running around." A staff member said, "Sometimes there are not enough staff. Sometimes we have 5 or 6 but sometimes when its 4 it's not enough to cater to people's needs."

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. We observed the service was clean and well maintained, free of malodour. Staff had access to personal protective equipment.

The provider did not always make sure that medicines and treatments met people’s needs, capacities and preferences. Where people had medicines to be given as needed (PRN), there was limited information available to guide staff. For example, medicines to support people’s emotional distress did not provide guidance on what the person’s distress may look like and at what stage the medicines should be given. Where people were prescribed pain relief, there was limited information about how to identify when a person was in pain if they could not communicate this verbally. However, medicines were stored safely and records showed people received their medicines as prescribed. The provider told us they would review all PRN protocols in the service. We will check for improvements during our next inspection.