Sutton Lodge

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment, the rating has changed to requires Improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of legal regulation in relation to, people’s safe care and treatment and good governance at the service. We have asked the provider to take action to improve the service.

This service scored 46 (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 make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Whilst there was a process to review people’s care plans, the reviews were not effective as they had not always assessed people’s needs effectively. For example, we found care plans that were incorrect or there were no care plans in place to ensure staff were provided with individualised information about all aspect of people’s care needs, including the impact of any health conditions. Where appropriate relatives had not been involved in reviewing care plans to ensure the information regarding their family member was accurate. One relative told us, “I have not seen the Care Plan for over 2 years.”

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

People were at risk of dehydration. Fluid intake records showed some people had not consumed sufficient fluids to maintain adequate hydration, increasing the risk of deterioration in their health, including urinary tract infections and constipation. There was a lack of effective monitoring and timely action to address low fluid intake. A relative told us, “The staff do know what they are doing but I did see a lady with dementia not drinking and the carer didn’t help.” People were also at risk of developing pressure damage, or further deterioration of existing pressure damage, because care was not delivered in line with their assessed needs and care plans. For example, one person’s care plan clearly stated they required repositioning every two hours; however, care records showed repeated delays and omissions in repositioning. This failure to follow the person’s care plan placed them at increased risk of pressure ulcers and caused unnecessary discomfort. These shortfalls demonstrated that care and treatment were not consistently delivered in line with evidence-based practice and did not adequately protect people from known risks.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

People’s care plans showed that referrals to external health professionals were not consistently made when people’s needs changed. For example, where records identified reduced fluid intake or changes in mobility, appropriate referrals to relevant health professionals were not made to obtain timely advice and guidance. Care plans were not always accurate or up to date, this meant there was a risk of incorrect or incomplete information being shared between staff teams and external service. This meant ineffective multi-disciplinary working and could result in delays in people receiving appropriate care and treatment

There was no effective or systematic process in place to ensure all staff were informed of changes to people’s care needs. Staff told us they relied primarily on verbal handovers to share information. However, they said that if they were not on shift when changes occurred, they were not always made aware of important updates. This increased the risk that people’s changing needs were not consistently recognised or responded to.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

Care plans and risk assessments did not consistently include person-centred information to support people to live healthier lives or manage long-term health conditions. For example, for people who were diabetic or pre-diabetic, there was limited guidance on how the condition affected the individual, how staff should support them, or what healthier food choices were available. Staff told us care was often task-focused, which limited opportunities to promote people’s independence. This meant people were at risk of losing skills needed to maintain their independence.

The provider did not always routinely monitor people’s care and treatment to drive improvement or ensure positive, consistent outcomes.

There was no effective system in place to monitor falls, fluid intake, or repositioning as cited within safe part of this report. This meant risks were not identified or managed in a timely way, and people did not always receive the care and support to improve their outcomes or to keep them safe.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

People had mental capacity care plans in place; however, records did not consistently show that mental capacity assessments had been completed in line with the Mental Capacity Act 2005, where people were assessed as lacking capacity. There were no documented best-interest decisions, and records did not show who had been consulted as part of the decision-making process.