Archived: Sutton House Nursing Home

Sutton House Nursing Home is registered to provide personal and nursing care to a maximum of 38 people, some of whom may be living with dementia or have physical disabilities. It is situated in the village of Sutton, close to local amenities. The home has three floors serviced by a passenger lift and stairs with single occupancy and shared bedrooms on the first and second floor. There is a large lounge area, a small quiet lounge and a dining room all situated on the ground floor. There is a garden at the front and the side of the building.

Sutton House Nursing Home 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.

The service had a registered manager. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found improvements had been made in the quality monitoring of the service delivered to people. The audits and checks highlighted when issues required addressing and were followed up by relevant staff. There were surveys, questionnaires and meetings in order for people to express their views.

There were improvements in the management of medicines and stock control was more effective. This meant that people received their medicines as prescribed and there were no delays when new prescriptions were issued.

Staff knew how to safeguard people from the risk of harm and abuse. They had completed safeguarding training and knew how to raise concerns and who to speak to about them. We saw people had assessments to help guide staff in how to minimise risk and keep people safe.

Staffing numbers had increased and were consistently maintained. There was a comment from health professionals about the difficulty in locating care staff, general oversight in the dining room and exiting the building at a peak time in the morning. Staff were busy supporting people to get up or administering medicines at this time. However, the registered manager told us they would resolve this by adjusting ancillary staff deployment at this peak time.

Staff recruitment was robust and employment checks were in place prior to new staff starting work. Staff had access to a range of training, supervision and appraisal which helped them to feel confident when supporting people’s needs.

People told us staff were kind and caring and their privacy and dignity was maintained. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice. People were treated as individuals and their rights protected.

We found people’s health care needs were met. They had access to community health care professionals when required and referrals to them were made in a timely way.

People’s nutritional needs were met. The menus provided choices and alternatives and special diets were provided. Staff supported people to eat their meals in a sensitive way and the lunchtime experience was a calm and sociable event.

There were activities provided seven days a week to help prevent isolation and encourage social interaction. Although there was an outside area for people to sit in during the warmer weather, there were plans for this to be improved to makes it more secure.

The provider had a complaints procedure displayed in the service. People felt able to raise concerns and staff knew how to manage them so they were resolved as quickly as possible.

The environment was clean and safe. Staff had personal protective equipment and there were procedures for infection control. Equipment used in the service was checked and maintained. There was a business continuity plan to guide staff in dealing with emergencies such as utility failures or floods. Each person who used the service had a personal emergency evacuation plan although these were included in their care file. The registered manager told us they would ensure a copy was included with an emergency pack to provide information to professionals if required.

Sutton House is registered to provide personal and nursing care to a maximum of 38 people. It is situated in the village of Sutton, close to local amenities. The home has three floors serviced by a passenger lift and stairs and has a range of single and shared bedrooms. There are several communal areas for people to use and a garden at the front and the side of the building. On the day of the inspection, there were 33 people using the service.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We had concerns about staffing numbers. There was insufficient staff on duty, especially in the morning and early evenings when people required more attention. The staffing shortfalls had impacted on call bell response times and in some instances on the delivery of care, for example nail and hand care.

Some people had not received their medicines as prescribed. This had been due to not obtaining medicines in a timely way before stock ran out. There was also an issue with some recording of medicines which was mentioned to the registered manager to address.

There were concerns that not all staff had the required skills to meet people’s needs. For example, there was a significant amount of staff that had not completed any dementia care training or how to manage people’s behaviours that could be challenging. There were also clinical areas that nurses had not received training in such as wound care, re-catheterisation and the management of syringe drivers used to deliver medicines when people were at the end of their lives. Staff had received a supervised training session and a discussion about their competency in how to support people with swallowing difficulties and also a supervision session on challenging behaviours.

Although the management and oversight of the service had improved and more thorough audits were completed, there remained concerns in some areas. For example, we had not received several notifications of incidents which affected the welfare of people who used the service. These must be completed by registered persons as they enable us to check how they are being managed and seek further action if required. We also asked the provider to complete a provider information return (PIR) but despite a reminder we have not received this. The PIR assists us when planning the inspection. Not all audits had identified areas to improve.

We are considering our regulatory response to the shortfalls in staffing numbers and training, medicines management and governance. We will report on this when it is completed.

There had been an issue with the assessment process for one person recently admitted to the service; full information had not been gathered before the person was admitted and their placement was in jeopardy. This had also been an issue at the last inspection. The registered manager told us they had difficulty obtaining the correct information. We have made a recommendation about the provider ensuring a protocol was developed and shared with commissioners which stipulated the documentation required to be in place prior to admission.

People had access to community health care professionals.

We found people's nutritional needs were met. There were choices and alternatives on the menus and people confirmed they liked the meals. We saw snacks and drinks were served in-between meals.

We observed staff approach had improved and saw they had built up good relationships with people. The atmosphere in the lounge and dining room at lunchtime was calm and relaxed which was a big improvement from the last inspection. Most staff showed they were caring towards people and respected their privacy and dignity. However, there was an impact on the care that staff provided to people as a result of staffing levels and the time they could devote to providing support. This impact affected call bell response times, choices for rising in the morning and the timings of meals for some people.

We found staff were recruited safely and full employment checks were in place before they started work in the service.

There had been improvements in risk assessments and care plans. These were much more detailed and provided staff with guidance on how to support people properly. Staff told us they liked the new care plans and they could find information more easily.

There had been improvements in how mental capacity legislation was adhered to. The registered manager had completed applications to the local authority when people lacked capacity and when their liberty was deprived. Staff were more aware of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. We saw examples of staff gaining consent from people before carrying out tasks.

There was a range of activities for people to participate in and information was displayed on the notice board. Some people chose not to join in and this was respected.

People knew how to make a complaint and provided names of specific staff they would speak with to raise issues. Staff had policies and procedures to guide them when managing complaints and concerns.

Staff told us they felt supported in the service and could raise issues with the registered manager or senior management if required.

There had been significant improvements in the cleanliness and safety of the premises. The environment was clean and tidy and issues raised at the last inspection such as broken radiator covers, clutter of equipment and accessible rooms with safety concerns such as sluices and hot pipes, had been addressed. There had been an issue with the lift breaking down with visitors inside but this had been addressed quickly and appropriate action taken.

At the time of the inspection, the service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service had a manager in post who had made an application with CQC to be registered; this was still being processed.

Sutton House Nursing Home was inspected in February 2016 and concerns were found regarding how people received personalised care, the number of staff on duty and how the quality of the service provided to people was managed through good governance. We issued requirement notices and received an action plan regarding the timescales the registered provider was to become compliant in these areas. An inspection to follow up the requirement notices was completed in July 2016 and we found improvements had been made in how people received personalised care and staffing numbers. However, although some improvements had been made to monitoring quality, there remained concerns about governance. We issued a warning notice for the registered provider to be compliant in this area by 19 August 2016. We also imposed urgent conditions on the registered provider’s registration to make sure guidance in how to manage accidents and injuries was available and all staff knew how to provide support should accidents and incidents occur.

We carried out this full comprehensive inspection to assess the service as a whole and also to follow up the warning notice and make sure the conditions of registration had been met. We found improvements in policies and procedures regarding how to manage accidents and incidents, and staff were knowledgeable about what action to take should someone have a fall. As a result we have decided to remove these conditions from the registered provider’s registration.

However, we found continued concerns with governance and oversight of the service and additional concerns in risk management, personalised care, infection prevention and control, medicines management, ensuring dignity and respect, staff training and the need for consent. As a result of inspection findings, the overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the registered provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

There were persistent concerns regarding quality monitoring and overall governance of the service. Some audits and checks had been completed but these had not been effective in identifying the shortfalls we found during the inspection. Some shortfalls which had been identified in previous audits had not been addressed in a timely way.

In three of the care files we looked at, we found the people had not had sufficient assessment of their needs prior to admission. One of the people was assessed by the local authority as requiring 24 hour specialist dementia care and although Sutton House Nursing Home did not provide this level of service, the person was admitted and will require an alternative placement.

We found not all people who used the service had risk assessments that identified areas of concern and steps the staff needed to take to minimise incidents occurring. Some incidents had occurred and staff were unsure of how to manage them.

We saw some people’s care plans lacked important information in order to provide staff with guidance in how to meet people’s needs in an individual way.

We found some people had not received their medicines as prescribed. This was due to a variety of reasons such as stock management and administration procedures.

There were times when the application of legislation such as the Mental Capacity Act 2005, used to protect people when they lacked capacity, was inconsistent. Not everyone had an assessment to determine capacity and a best interest meeting to discuss decisions, when care restrictions were in place such as lap straps and bed rails. The manager had taken action and sent in applications to the local authority when people’s liberty had been deprived; some of the applications had been authorised but several people were awaiting assessment by the local authority.

We saw some positive interactions between staff and people who used the service and a caring approach. However, some areas of interaction and how staff looked after and stored people’s dentures and toothbrushes required improvement to ensure privacy and dignity was maintained. Also we saw records were held securely and conversations with health professionals were held in the nurses office; however, the size of the nurses office posed a risk that confidential discussions, held during reviews with a group of people, could be overheard as the door had to be left open to accommodate more than two chairs.

There was a lack of signage around the service to remind people of where their bedrooms, toilets and communal rooms were.

Not all staff had received the level of training required to meet the current needs of people who used the service. This meant some people may be at risk of not receiving appropriate care and support.

Staff were recruited safely and there were enough staff on duty. However, how staff were deployed at certain times of the day or how shifts were organised, for example at mealtimes, meant people did not always receive support in a timely way. We have made a recommendation about this.

Some areas of the service posed a risk to infection prevention and control. Items of equipment had not been cleaned and stored properly, areas of the service required cleaning and there was a lack of hand hygiene guidance in communal hand washing areas.

We found some areas of the service and equipment such as radiators posed a risk to people. People who used the service had access to areas that were hazardous such as the boiler room, sluice rooms, store rooms and they also had access to potential harmful products stored in a communal toilet.

People told us they liked the meals provided and we saw there were menus which detailed choices and alternatives. Special meals were provided for people with individual dietary needs and swallowing difficulties.

People had access to activities to provide them with stimulation.

Staff had received training in how to safeguard people from the risk of abuse. They knew the signs to look out for and what to do if they had concerns.

Staff told us they felt supported by the manager and could express their views. The staff supervision and appraisal process had commenced which the manager said would be used to establish training and development needs.

We saw there was a complaints procedure and people felt able to raise concerns. They told us they were confident the manager would address complaints.

The service had a manager in post as required by a condition of registration and they had started the process to be registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We undertook this unannounced inspection on the 14 and 20 July 2016 to follow up progress with requirement notices for concerns we had with person-centred care, staffing and quality monitoring at the inspection we completed on 2 and 3 February 2016. At the time of the July 2016 inspection there were a total of 34 people living in Sutton House Nursing Home.

As we have not completed a full inspection, we have not changed the overall rating for the service, which remains at 'Requires Improvement'. We will be monitoring the service and completing further inspections to check on progress.

We had concerns with how staff monitored two people when one of them had a fall and sustained a head injury and the second person had an unresponsive episode for five minutes. We found staff did not have clear guidance on the action to take following such incidents and recording of monitoring people was limited.

In answer to this we have used our urgent powers under s31 of the Health and Social Care Act 2008 and imposed a condition on the registered provider's registration regarding the management of accidents and incidents which affect the health and safety of people who use the service. You can see the timescales for the registered provider to be compliant with this at the back of the main body of the report.

We found some improvements had been made with the development of an audit system and seeking people's views. However, an important element of governance is about learning from past incidents to ensure practice is improved. We found there was a failure for lessons to be learned in an area of observing and monitoring people following incidents that affected their safety, health and wellbeing.

In answer to this we have issued a warning notice to the registered provider regarding Governance and lessons to be learned from accidents and incidents to prevent a reoccurrence. You can see the timescales for the registered provider to be compliant with this at the back of the main body of the report.

We found improvements had been made with regards to the numbers of staff on duty. At the last inspection, we had concerns there were insufficient numbers of staff to meet the needs of people who used the service. The numbers of staff on duty during the day has increased by two care staff and at night by one care staff. A nurse has been recruited for a new clinical lead role to oversee clinical issues and to be a link between the qualified nurses and the new manager, who is also a nurse. There has been some improvements regarding staff training and ensuring care and nursing staff are equipped with the skills required to support people safely. However, we had some on-going concerns regarding the level of skills demonstrated by some staff when people who used the service were involved in incidents which affected their safety, health and wellbeing.

We found there had been some improvements with the delivery of person-centred care and the development of individualised care plans. One care plan we looked at was very person-centred and contained lots of information about their preferences for how care was to be delivered. New care plans had been introduced and staff had started to input more personalised information into them. However, we found this was a slow process and important details were missing from some people's care files which could affect the care they received. We did find, however, that staff had a good knowledge of people's needs and how they were to be met.

You can see what action we have asked the registered provider to take, regarding the concerns in the two paragraphs above, at the back of the full inspection report.

We undertook this unannounced inspection on the 2 and 3 February 2016. There were 36 people using the service at the time of the inspection. At the last inspection on 14 January 2014, the registered provider was compliant in the areas we assessed.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A member of staff had been the acting manager of the service since September 2015 and a new manager had been appointed and started their first day in the role on the day before the inspection. They will begin the process of registration with CQC.

We found people had access to community health care professionals and assessments of their health care needs were made. However, there were instances when staff did not monitor people’s health care needs effectively and had not sought medical intervention in a timely way.

We found the quality monitoring system had not been implemented fully and had not been effective in highlighting areas to improve such as the care records and the environment. Action plans had not been produced in order to address shortfalls. Accidents had not been analysed to help find ways to reduce them.

We found there were times when there were insufficient staff deployed to meet people’s needs.

The above issues meant the registered provider was not meeting the requirements of the law regarding assessing and delivering person-centred care, having an effective monitoring system and ensuring sufficient numbers of staff are deployed at all times. You can see what action we told the registered provider to take at the back of the full version of the report.

Care plans were produced so that staff had guidance in how to support people. We found these contained some personalised information but could be improved to ensure staff had full information on how people preferred to be cared for. People had risk assessments completed to help staff to minimise any areas of concern. We found some areas of risk had been overlooked. These points were mentioned to the new manager to address.

We have made a recommendation about the formulation of person-centred care plans.

People told us they liked the meals provided and they had plenty to eat and drink. On some occasions we saw people’s weight had been recorded but we were unsure if action was taken when there was a loss identified or that this was followed up by further weight monitoring. We found some people were under the care of the dietician. The new manager told us they would address this with staff.

People generally received their medicines as prescribed and they were obtained, stored and recorded appropriately. However, on the day of inspection, the nurse administering medicines had lots of distractions which meant some people’s medicines were late. We saw there was no impact on people because of this situation.

People told us staff were caring and kind. We saw staff were very busy and this impacted on the attention they were able to devote to people. We observed some areas of staff practice that could be improved and the new manager is to address this with staff.

We saw information relating to people’s care and treatment was handled in a confidential way but personal records were not always stored securely.

We found staff knew how to safeguard people from the risk of abuse and had received training in how to recognise the signs and symptoms and how to pass on information of concern.

We found staff were recruited safely and had employment checks carried out before they started work in the service. Staff had access to training and supervision. A training analysis had just been carried out by a senior manager and they had planned a series of courses to ensure all staff had up to date certificates in essential training. We were unable to see the induction records of two new staff although one spoke with us and told us they had received mentoring from another member of staff and induction consisted of shadowing and working through booklets.

There was a complaints process that was on display and people told us they would raise concerns if required.

People told us they liked the meals provided to them and said they had choices and alternatives. The cook catered for different nutritional needs. Comments included, 'The food is lovely. I am a diabetic and they always keep stocked up with diabetic juices. If you don't like it then they take it back and fetch something else.'

We found the service provided a warm, clean and safe environment for people and there was sufficient equipment to meet people's assessed needs.

We found there was sufficient skilled and experienced staff to meet people's needs. People who used the service said staff respected their privacy and dignity and treated them well.

We found people who used the service and their relatives were asked for their views via questionnaires and in meetings. The manager and other staff completed audits of the service so that shortfalls could be identified and addressed.

We found that people's health care needs were met and medicines were managed appropriately. People spoken with told us that staff looked after them well and helped them to be as independent as possible. They said they could see their doctor when required and received their medicines on time. One person said, "I'm not sure if I could be looked after any better."

We found the home to be clean and tidy. People spoken with said staff cleaned their bedrooms each day. We found some chairs in the lounge to be stained but the manager was going to address this.

People spoken with told us they felt able to complain and would tell the manager or other staff if they had any concerns. Comments included, "I have no worries at all but l would tell the manager if I did."