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 was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 56 (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 did not always have a proactive and positive culture of safety based on openness and learning. Lessons were not always learnt to continually identify and embed good practice.Although staff recorded accidents and incidents appropriately and the leadership team monitored and acted. There were not regular staff meetings, where there were opportunities for staff to reflect on what went wrong and what action could be taken to mitigate risk in the future. Opportunities for lessons learnt were missed by the leadership team to enable the staff to embed good practice.

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.

A preassessment was completed by a member of the leadership team before people moved into Sutherlands Nursing Home. Staff worked closely with GP’s and healthcare professionals, and concerns were escalated and appropriate referrals to healthcare professionals such as occupational therapist and speech and language therapist (SALT) were made.

The provider did not always share safeguarding concerns quickly and appropriately with CQC. For example, we found 2 incidents where referrals to the local authority safeguarding team had been made and it was recorded that CQC had been notified. When we asked the provider for confirmation that they had notified us, they could not evidence they had. We requested the notifications to be sent to us retrospectively. However, staff received safeguarding training and demonstrated a clear understanding of the services procedures of reporting concerns.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments were in place for people needing to be repositioned regularly due to risk of skin damage. However, we found some people were not being repositioned in line with their risk assessment. For example, we found monitoring charts for some people who required support to reposition every 2 hours or every 4 hours to reduce the risk of skin damage, were not being repositioned within this timeframe placing them at risk. We found no harm had come to people.When we informed the leadership team, they were proactive in reviewing our concern. The leadership team reviewed all people at risk and ensured regular oversight was made.

The provider did not always detect and control potential risks in the care environment. For example, during our inspection we found the kitchen door leading from a communal lounge unlocked and unattended, the exit door for the kitchen was unlocked which led to access to the main road at the front of the home through gates which were not locked. We found no fire sensor in the clinic which had an electrics panel present and flammable creams stored within it. We also found people’s prescribed thickener was accessible in an unlocked cupboard. People using the service are vulnerable and potentially unable to determine what is safe independently. These concerns potentially put people at risk of harm; however, we found no harm had come to people. We shared our concerns with the leadership team who acted upon our concerns promptly and put strategies in place to protect people from the risks we identified.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

During our inspection we saw people in the lounge being left with no staff present for prolonged periods of time. Staff told us this was not usually the case and was due to staffing levels that day. Relatives told us that they felt the staffing levels could be stretched at busy times. A relative told us, “There’s probably not enough staff, though it’s not caused any issues.”

We raised our concern with the leadership team, and they reviewed staffing levels in line with the service’s dependency tool, this is used to identify the number of staff required for the level of support people required. Following the leadership review of staffing, the provider increased the staffing levels at Sutherlands nursing home

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.

The service had structured cleaning schedules which were monitored by the house keeping team. The home presented clean and during our inspection we saw staff adhered to infection prevention controls (IPC) and wore aprons and gloves when supporting people with their needs.

A staff member told us, “We have cleaning schedules which we follow.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People’s medicine’s records showed that they received their medicines safely and as prescribed. Staff were knowledgeable about people and their medicines.

There were suitable arrangements for ordering, storage and disposal, including medicines requiring cold storage and those requiring extra security. Suitable temperature monitoring was carried out to make sure medicines were safe and effective.

Staff had suitable, up to date training, and the provider carried out medicines audits to support safe medicines management.