Sutton Hall and Lodge

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 inspection we rated this key question requires improvement. At this inspection the rating has remained 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 safe care and treatment relating to medicines and risk management, safeguarding/ MCA and staff supervision.

The provider was previously in breach of the legal regulation in relation to premises and equipment. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Accidents and incidents were recorded; however, managers did not always analyse these for themes or patterns. Lessons were not always learnt to continually identify and embed good practice. The provider was responsive when we raised these concerns with them. Plans were put in place to improve the use of the providers system of oversight and analysis.

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.

The provider could not evidence they were meeting the requirements of the Mental Capacity Act 2005 (MCA). Records relating to MCA and Deprivation of Liberty Safeguards (DoLS) were not complete or up to date. Care records relating to people’s capacity were contradictory. Some MCA records were tick box only, with no detail or follow up on best interest decisions or records. Staff training completion for DoLS MCA was very low and staff had a lack of knowledge regarding DoLS MCA. DoLS oversight records were not up to date and indicated many DoLS had expired. During our inspection managers and staff were unable to confirm who had a DoLS authorisation in place, or if any had conditions placed on authorisations.

Following the inspection, the provider confirmed they were in the process of checking the status of DoLS applications and authorisations with the relevant local authorities, and updating records.

Staff had received training in safeguarding people from abuse. The provider worked well with people and partners to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. People told us they felt safe living at the home. One person said, “I feel safe. My [relative] had a look round a few places; this was one of the better ones.”

People were involved in identifying risks to them. However, risk assessments and care plans did not always effectively address those known risks. They contained contradictory information and were not aways accurate or complete. There was evidence of regular review, however reviews had not always identified missing information or ensured records were updated effectively or accurately when changes occurred.

A number of people had ‘as and when required’ (PRN) medicine for distress. Care records were not sufficiently detailed to guide staff on when it should be used, or alternative de-escalation to try. There was no evidence of monitoring of its use. Behavioural support plans were either absent or not sufficiently detailed. There was no detailed records of events prior to, during and following incidents (ABC) or that staff had received a debrief or support. There was no evidence of detailed analysis of incidents for themes or patterns.

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

All required health and safety certification and checks were in place. Some areas of the home were in need of redecoration, there was an ongoing programme of update and redecoration. Bath chairs did not have risk assessments or suitable lap belts available. The provider confirmed this had been actioned following inspection and that risk assessments would be completed, and where needed best interest decisions would be undertaken.

The provider ensured there were enough staff to provide people with the care and support they required. They did not always make sure staff received effective support, supervision, training and development.

Staff supervisions were very infrequent and some staff told us they did not feel supported. There was no evidence of clinical supervisions for nurses during 2025. There had been some improvement in supervisions the month prior to our inspection, and the provider showed us that further supervisions for all staff were planned. All required checks had been undertaken prior to people commencing employment at the service. Staff received training to enable them to carry out their roles. However, some gaps in training completion and staff knowledge were evident, particularly regarding MCA and DoLS. There was a lack of trained fire marshal deployment, and action was underway to improve fire drills and emergency evacuation training.

People told us they got the support they needed in a timely way. People said, “I think there’s always plenty of staff. They help me and they look out for me” and “Sometimes they could do with an extra pair of hands, they are sometimes in a rush. But I keep my door open and they always check in on me when they are going past. Some pop in and give me a hug or a fist pump.”

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

The home was clean and appropriate infection control measures were in place.

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

Temperatures of treatment rooms, where medicines were kept, were not always monitored daily. One of the treatment rooms was routinely above 25 degrees which put medicines at risk of being stored above the recommended temperature.

Creams were kept within residents’ bedrooms, and topical body maps were not always available to show staff where to apply these correctly. It was not always clear if these had been applied, when manually entered on the electronic notes system.

People that were prescribed PRN medicines did not have up to date protocols in place to ensure staff would know how and when to give these safely. When PRN medicines were administered, full documentation was not always evident to reflect the correct processes were followed.

Some medication administration records (MARs) were handwritten and did not have all information present, including dates and full medicine details. These were not always checked by two members of staff. There was one resident who had gone an extended period of time without their treatment which related to a specific long term condition. No escalation procedure was evident in their records.

Controlled drugs (CDs) were stored securely, but due to their potential for abuse and misuse regular stock counts should be carried out. This was not evident in the home’s CD registers.