Updated 18 September 2025
Date of assessment: 15 October to 2 December 2025. Sutton Grange is a care home, providing accommodation for people who require nursing or personal care, and treatment of disease, disorder or injury. The home can provide support for up to 70 older people or younger adults, including those living with dementia, or a physical disability. At the time of -this assessment, 57 people were living at the home.
An unannounced inspection took place to review the quality of care, following information we received about staffing levels, medicines management systems and moving and handling practices. At the last inspection, the home was rated good. At this inspection we found standards had declined and the home was now in breach of legal regulations for dignity, safe care and treatment, and good governance.
Risks to people were not always recorded or managed safely, and strategies to support people communicating a need, emotion or distress were not consistently followed. The provider used a dependency tool to calculate staffing levels, but feedback and observations evidenced staff deployment did not ensure consistently safe, good quality care. Medicines were not always managed safely and people did not always receive their medicines as prescribed.
Staff no longer ensured information in care plans was robust, and records indicated people did not always have the required support to prevent malnutrition or dehydration. Recognised tools were used to record observations when staff noted signs of ill health, but these were not consistently used to monitor or prevent deterioration. Care plans lacked information about people’s oral hygiene needs and records evidenced prolonged periods where some people went without adequate support.
The provider did not ensure staff deployment always afforded compassionate care, which meant people’s dignity was impacted. Care was task led at times. Staff could not always respond to requests for care and support in a timely manner.
Governance and oversight systems had not been effective in identifying concerns found during our inspection, or ensuring these had been rectified in a timely manner.
However, there were effective systems to manage and learn from safety events and information was shared with the appropriate agencies. Information was available to support people to prepare for moves between services . Deprivation of Liberty Safeguards (DoLS) were in place as required, and renewal dates of authorisations were monitored. The environment was found to be safe, secure and hygienic. Staff were recruited safely, and received the appropriate training and support.
The provider ensured information about people’s needs were shared with staff, and worked closely with healthcare partners where required. Care plans were outcome focused and managers regularly reviewed people’s outcomes. Staff sought consent in line with the Mental Capacity Act 2005 (MCA), and promoted people’s choice and control.
Staff had a good understanding of the needs of the people they supported, and continuity of care was prioritised. People received information in a way they could understand, and systems were in place to enable people and relatives to give feedback. The home was adapted to meet the needs of those with protected characteristics. People were supported to make advanced decisions about end of life care.
Staff were made aware of the home’s visions and values, and managers led by example. Staff told us they felt they were treated fairly and felt confident speaking up. The home worked in partnership with other homes and services, collaborating to improve people’s experience. There was adequate investment to enable staff to develop their own skills and make improvements to the environment.
Following feedback, managers took action to address some of our concerns around care plans, record keeping and medicines management. We have asked the provider for an action plan in response to the concerns found at this inspection.