Sutherlands Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to good governance at the service.

This service scored 54 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

For example, staff told us that the frequent change in the management led to continued change and lack of stability. A staff member told us, “I do think the management changes have impacted the staff, because things change and then change again. At the time of our assessment a new home manager joined the service.

Leaders did not always have the knowledge needed to lead effectively. For example, the leadership team did not identify, recognise, and address safety concerns we found. While we had confidence in the leadership team’s ability to reduce risk following our feedback, continued improvement was needed to ensure they retained overall oversight and actioned risks identified in a timely manner. We were not assured the processes the provider had in place would have identified the areas of improvement found during our assessment.

However, the leadership team demonstrated to staff they were approachable and accessible. A staff member told us, “I am treated fairly and [manager] is approachable.”

Relatives told us that the leadership team were approachable and they were making positive movement in the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service has processes to support staff in speaking up and raising concerns.

This included policies in relation to whistleblowing and safeguarding.

A staff member told us, “Line managers treat me with respect, I can always tell them what I think and feel and concerns, they listen to my ideas for improvement.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Systems were in place to encourage staff feedback, through a daily catch-up meeting, supervisions and an accessible leadership team. Policies and procedures promoted an equitable workplace.

Staff told us they felt confident in raising concerns. A staff member told us, “Had my supervision yesterday, [manager] is good, approachable and I can always talk to [manager].”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The providers audit and quality assurance of key areas of service provision did not identify the concerns we found during our assessment. We found concerns which included 2 fire doors not closing, unlocked and accessible kitchen, people’s prescribed thickener was accessible in an unlocked cupboard, the complaint information for people had the incorrect Nominated Individual’s details, people’s toiletries were not always treated with respect, the medicines storage area contained an electrical switch board and stored flammable creams with no fire sensor in place and notifications had not been sent to CQC. People were not always being supported to reposition in line with the required time regime, a person’s recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was not dated or have the person’s location.

This meant issues were not always monitored appropriately to reduce risk to people and to drive change. We found no harm had come to people. The leadership team responded when we raised concerns and provided evidence of improvements made.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider worked with healthcare professionals to ensure that people received the appropriate support for their needs. The provider did not work effectively at supporting people to be part of their community. Staff told us that people do not get the opportunity to go out. A staff member told us, “A person has gone to Waitrose, and another goes to their day centre, but otherwise people don’t go out.”

Relatives told us that there were activities within the home. A relative told us, “There was talk of taking people out, but it’s not happened.”

However the activities staff told us they organised events for the community to come into the home, this included befrienders, religious groups, entertainers and annual fetes.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Inconsistencies in systems used to identify learning and make improvements were not always effective. For example, quality assurance systems did not identify the concerns we found. This did not enable the provider to measure and improve change. The provider lost opportunities to develop staff through regular team meetings incorporating lessons learnt.