Sunningdale Court-Care 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 good. At this assessment the rating has changed to 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 receiving safe care and treatment, safe staffing and the way people’s medicines were managed.

This service scored 50 (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 honesty. Lessons were not always learnt to continually identify and embed good practice.

Lessons learned from accidents and incidents were not being consistently captured or reviewed. The service did not always analyse events to identify trends or patterns that could reduce future risks. Systems were not in place to review these and capture learning from them. Following safety events, staff were not given a formal opportunity to discuss these events to aid learning and support well-being. One staff member said, “I have never had a debrief.” Following this assessment the provider stated they were taking action to make improvements in this area.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

The provider did not ensure that essential information needed for people to safely transfer between services was current or accurate. One person’s hospital passport had incorrect information recorded in relation to their dietary requirements and specific nutritional needs including the incorrect consistency of meals they required. This lack of information increased the risk of delays or inappropriate actions if a person required support from another service, such as a hospital, potentially placing both the person and staff at risk.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately.

Policies were in place to help ensure people’s safety, such as a whistleblowing and safeguarding policy. Staff understood risks regarding abuse and/or person safety and were able to explain how they would report a safeguarding concern.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found assessments and applications had been made in line with the recommended procedures to support people to live the lives they chose. 

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 but not always followed in practice, which placed people at risk of avoidable harm. People had risk assessments that covered key areas such as nutrition and hydration, and skin integrity. Daily records and our observations showed that staff did not consistently follow the guidance set out in these assessments. For example, people required regular repositioning to support with skin integrity, but this was not always completed in the time frames documented in the risk assessments potentially placing the person at risk.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider did not complete all required building checks, which increased environmental risks. The provider was required to complete fire alarm tests weekly; however, this did not always happen. Furthermore, there was a range of rooms that were supposed to be locked at all times, this included room with personal protective equipment (PPE) and trips hazards that would pose a risk if people entered them. Across the 3 bungalows these rooms were consistently open. This was highlighted during the assessment but at times throughout the day the doors remain unlocked. Following this assessment, the provider stated they were taking action to make improvements in this area.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

Staff were not always deployed effectively, and some communal areas of the home were left unattended. A dependency tool to determine safe staffing was in place but this had either not been consistency competed or completed inaccurately. Staff told us there was not enough staff, and they couldn’t spend time with people to talk to them. A staff member said, “We are always understaffed.” A relative also said, “There are not enough staff. In the past we have had to go look for staff.”

The provider could not evidence staff had received all the necessary ongoing training to carry out their roles safely. For example, some people living at the service had a learning disability, but staff had not been trained in how to support people with a learning disability. When agency staff were used, they had not always been provided with an appropriate induction.

The provider had a recruitment system in place to help them select staff which were appropriate to work with vulnerable people. Pre employment checks had been carried out prior to them commencing employment at the service.

The provider did not always assess or manage the risk of infection.

The provider did not ensure they prevented and controlled the risk for infection prevention and control. The control of substances hazardous to health (COSHH) room contained a sluice sink that was used for emptying mop buckets. However, cleaning products were not fully enclosed or stored within a closed cupboard. This presents a risk that infectious particles can become airborne and contaminate exposed cleaning products, such as washing-up liquid.

The provider had an infection control policy in place, but this was not always adhered to. For example, there was no designated hand washing sink with the COSHH room, however this was required in the infection control policy. Within the COSHH cupboard there was no appropriate clinical waste bin for the disposal of personal protective equipment (PPE) if required following the cleaning of bodily fluids. As a result, staff were required to remove potentially infectious PPE and exit the COSHH cupboard to access the communal bathroom for disposal and to wash their hands. If this bathroom was occupied, staff were then required to walk to another bungalow to wash their hands and dispose of the PPE. This increases the risk of infections spreading.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medication administration records (MAR) charts were not completed correctly; medicines were signed for but they were not administered as prescribed and exposed residents to potential harm. For example, medicines that were a prescribed regular dose medication was offered given on a ‘as and when required (PRN) basis.

PRN protocols were either minimal or missing, offering insufficient guidance to support safe and consistent medicine administration. Where PRN protocols were in place, staff did not always follow them. For example, we observed 1 person repeatedly asked staff to rub their head, which the protocol identified as a potential indicator of pain. However, staff did not explore whether the person was experiencing pain or consider offering their PRN medicine for pain. This lack of response to known signs of discomfort meant the care provided was not person‑centred and placed the person at risk of avoidable distress.

Some people required emergency rescue medication, for example epilepsy medication to manage seizures. However, staff did not ensure people had access to this medication when they went into the community. The failure to ensure its availability meant risks were not adequately assessed or mitigated.

Some people required the use of thickeners as they were at risk of choking. However, professional guidance provided by Speech and Language Therapy (SALT) in relation to this was not always followed or consistently applied. This created a risk of aspiration or unnecessary restriction and did not support safe, effective care.