Background to this inspection
Updated
24 August 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
This inspection was carried out by one inspector and a nurse specialist professional advisor (SPA). An expert by experience also spoke with some relatives on the telephone. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Sutton Rose is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
At the time of the inspection, the service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced; however, we gave notice of the inspection when we arrived in the car park because of the risks associated with COVID-19 and to ensure everyone remained safe during our inspection site visit.
What we did before the inspection
We checked the information that we held about the service. This included statutory notifications sent to us by the provider about incidents and events that had occurred at the service. A notification is information about important events which the service is required to send us by law. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection-
We spoke with four people who used the service and eight relatives about their experience of the care provided. We spoke with 12 members of staff including the director of regulation, registered manager, nurses, care workers, house keepers and the chef. We also spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at three staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found and due to COVID-19 we reviewed several records off site.
Following feedback provided during and after the inspection, the provider informed us they had started to address the issues raised.
Updated
24 August 2021
About the service
Sutton Rose is a care home providing personal and nursing care to 22 people aged 65 and over at the time of the inspection. The service can support up to 85 people. The accommodation is organised into three floors, each with its own communal areas.
People’s experience of using this service and what we found
Audits were carried out by the management team and the provider, but they failed to ensure medicines were always safely managed, care records were accurately completed, and CCTV was used in line with current CQC guidance.
People did not always receive their medicines as prescribed. People had personalised care plans and risk assessments which gave staff the information needed to safely manage the risks associated with people's care. However, the consistency and quality of health and care monitoring records required improvement.
There was an overt surveillance CCTV system fitted in bedrooms within the home. The registered provider told us it was primarily to protect the safety of people and footage was only viewed if an incident or serious fall occurred. Full consideration had not been given to ensure people’s privacy in their bedroom had been fully assessed.
People said they felt safe living at the home. Staff had received safeguarding training and were aware of their responsibility to report safeguarding concerns. The provider had systems in place to manage concerns of a safeguarding nature.
The environment was safe and well-maintained. The home was clean and effective infection prevention and control measures were in place.
Staff were visible around the home and were readily available to support people when needed. We observed kind and caring interactions between staff and the people who lived at the home. The registered manager had a good rapport with people living at the home and staff.
Staff had the skills and knowledge to meet people's needs. Balanced and nutritious meals were served, and people were complimentary about the quality of the food.
People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service support this practice.
People were supported to maintain contact with their friends and families. There were opportunities for social stimulation. People felt their concerns and complaints would be listened to and responded to.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 9 December 2020 and this is the first inspection.
Why we inspected
This inspection was carried out due to the length of time the provider had been registered with CQC without receiving a formal rating.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to safe care and treatment and good governance.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring and well led relevant sections of this full report.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.