Sutton Grange

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 safe care and treatment, including how people’s medicines were managed.

This service scored 62 (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 provider’s systems and processes ensured safety incidents were appropriately investigated and reported. Incidents were clearly documented and well organised. The matrix was updated monthly, detailing referrals made to the local authority and duty of candour requirements.

There was a culture of learning from incidents and other safety events, and learning was communicated and acted upon. There was evidence investigations had been held to determine the root cause of safety events, and appropriate actions put in place to help prevent reoccurrence.

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 virtual tour and welcome booklet were available to help prepare people for their move; and the registered manager completed pre-assessment paperwork, which included information about people’s needs, preferences and personal history. Information was shared with staff, so they were aware of people’s needs as they moved into the home.

The provider worked with people and relatives to plan care and support and ensure there was a collaborative and joined up approach when people moved in to or out of the home. A relative said, “Someone from Barchester came to visit us. [Person] tried it out on respite first and then moved in permanently.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse and discrimination. The provider shared concerns quickly and appropriately.

The provider had clear safeguarding systems and processes, to protect people from abuse and share concerns with other agencies. A safeguarding file was used to record information about potential safeguarding concerns and track actions taken. Incidents were checked against local authority guidance to assess whether a referral was required. Referrals made were well documented.

When receiving care and treatment, people can only be deprived of their liberty with the appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked how the provider managed DoLS within the home. The provider ensured DoLS applications were made for the relevant people. A system was in place to monitor renewal dates and review conditions.

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.

Staff did not always ensure risks relating to people were assessed and managed appropriately. A person was observed to enter other people’s bedrooms, posing a risk to themselves and others. This had not been risk assessed, to reduce reoccurrence, or guide staff of the appropriate intervention. Several other risk assessments were found to contradict with people’s care plans, or had been prepopulated with incorrect information.

Information about the frequency of repositioning and wellbeing checks was not always clear, correct or consistently followed. One person required repositioning at set frequencies, and staff were instructed they should only be positioned on their left or right side to prevent further deterioration to their skin. Records showed guidance had not always been followed. Another person required hourly checks following administration of pain medication due to the increased risk of falls, but these had not been consistently carried out.

Staff were trained to manage distressed reactions, and a dementia nurse reviewed people’s needs and identified appropriate strategies to support those displaying high levels of distress, but these were not consistently followed. One person’s mood could fluctuate, and their care plan clearly identified strategies needed to reduce distress. Records indicated they had not been supported consistently to maintain their wellbeing, and agreed strategies had not always been used to prevent or respond to distressed behaviour . A medication review had been requested, despite less restrictive approaches not being adequately trialled or embedded.

Following feedback, the registered manager ensured risk assessments and care plans were reviewed for those identified.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider ensured facilities and equipment were well-maintained, used for their intended purpose and supported staff to deliver safe and effective care. The home was observed to be safe, secure and well maintained, and the appropriate adaptations had been made to help prevent safety incidents.

There were effective arrangements to monitor the safety and upkeep of the premises. Daily walk arounds were completed to monitor for environmental concerns, and a maintenance person was employed to conduct regular health and safety checks, scheduled maintenance and emergency repairs. External servicing had been carried out at the required frequencies.

The provider had effective fire safety procedures and staff had access to fire safety training and regular drills. Fire safety measures such as emergency lighting, evacuation equipment and extinguishers were in place.

The provider did not always make sure there were enough staff, but staff were safely recruited and received effective support, supervision and development opportunities.

The provider did not ensure there were appropriate staffing levels to provide consistently safe, good quality care that met people’s needs and protected staff wellbeing. A dependency tool was in place to calculate staff numbers, but we received feedback from several staff members, people and relatives that deployment was not effective. A staff member said, “I don’t agree with the staffing levels but know the ratio is worked out using a dependency tool. Staffing levels can massively impact people; longer wait times, family members don’t always have chance to speak to us quickly, I don’t always have time to do my job well, welfare checks are strained.” Please see the caring section of this report for more information.

The provider had robust recruitment processes to make sure staff, including agency staff, were suitably experienced, competent and of good character.

Staff received training appropriate to their role and training was refreshed at the required intervals. The training matrix evidenced good levels of training, and staff confirmed they had access to additional courses or webinars to improve their knowledge of key subjects. Nurses were provided support with professional development requirements. A training champion helped monitor staff training.

The provider assessed and managed the risk of infection. They detected and controlled risks and shared concerns with appropriate agencies promptly.

The provider had effective systems to assess and manage the risk of infection, and staff maintained good standards of cleanliness and hygiene. The home was generally clean and tidy, with housekeepers working during our visits. A relative told us, “Cleanliness is good, but we may sometimes have to request staff clean the bath or bedroom.”

Staff understood the importance of food hygiene, when preparing and handling food. The kitchen was clean, hygienic and well organised, and staff wore the appropriate personal protective equipment (PPE) when serving food and supporting people at mealtimes.

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

Staff did not always keep contemporaneous records of people’s medicines. We observed staff on 2 occasions signing the MAR (medication administration record) prior to people having taken their medicines. We also found gaps in records of administration, and running balances of medicines indicated people had not always received the correct dose. Staff did not always record when medicines were disposed of, in line with the provider’s own policies.

Records did not always reflect that medicines were administered as prescribed. A person’s prescribed creams were not applied as instructed and another did not get their laxatives as prescribed. Records indicated thickened fluids were not always prepared appropriately for people at risk of choking or aspiration.

Staff had not always documented the time medicines were administered for medicines which were time sensitive, so we could not be assured these medicines were administered safely, as prescribed.

Instructions for medicines given when required (PRN) were not always available and when they were present, they did not contain enough person-centred information to guide staff. One PRN protocol did not contain the correct information regarding the dose of medicine a person could have which put the person at risk of receiving the wrong dose.

For people who had their medicines administered covertly hidden in food and drink, there were covert administration plans in place, agreed by the relevant healthcare partners. However, some plans did not contain information for all medicines prescribed covertly, so we could not be assured medicines given this way were always administered safely.

Audits of medicines were completed by the service and although the audit had found issues with fridge temperature monitoring in July and August 2025, we found this was still an issue on the day of the inspection.

However, medicines were managed by staff who had been trained and had their competency assessed.

Following our assessment, the provider reviewed the necessary covert administration plans and PRN protocols. Additional supervision and support was organised for staff responsible for administering medicines.