Sutton Court

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

We assessed 7 quality statements within the safe key question. People were safe and were not at risk of avoidable harm. Safe systems were in place to manage risks. People, family members and external health and social care staff told us they felt the service was safe. Where things went wrong there were systems to identify, manage and learn from the incident.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were safe. Staff and leaders promoted an open proactive culture to safety events. Incidents were reported and investigated this resulted in lessons learnt and supported continued improvement of practice. People and their relatives spoke positively about the staff and management team. They told us they could approach them with any ideas, worries or concerns. They had confidence action would be taken. The provider and managers were open and transparent, and it was evident they had worked hard to improve the service to provide people with safe, effective and person-centred care. One staff member said, “It’s easy to report anything, we talk about things so we can do better if it happens again.” There was a robust process in place to monitor incidents, accidents and near misses. This ensured all accidents or incidents were individually reviewed and prompt action could be taken where required. Incidents and accidents were formally analysed monthly. The service demonstrated organisational learning and continued improvement.

People told us they felt safe at the service. One person said, “I like it here, I can have a chat with [name of home manager] if I want too.” Staff demonstrated knowledge about their role in safeguarding people. Positive behaviour support plans were in place for people who needed them, and staff were able to tell us how they implemented the guidance into practice. People had Deprivation of Liberty Safeguards (DoLS) documents in place where appropriate and staff and leaders received training in this area. DoLS had been approved by the local authority and notifications sent to CQC in line with current best practice. Safeguarding policy and procedures were in place and instructed staff how to recognise, report and record abuse. Staff had access to a whistle blowing policy and were encouraged to make concerns known. The service had a full record of safeguarding concerns, and this included the type of abuse, people involved and description of the incident as well as the outcome and any lessons learned.

Risks were managed in a way to support people to be as independent as possible and so that they could enjoy activities they liked doing. The registered manager and staff demonstrated detailed knowledge of the needs and preferences of people living at Sutton Court. Management ensured risks to people were regularly reviewed, and guidance to staff updated, if needed. Staff were knowledgeable about risks to the people they supported. For example, where people required support to manage their health conditions. Staff spoke confidently and accurately about the support people needed to manage their epilepsy and other health conditions. In recent years people were supported to take more positive risks balancing their safety and their wishes. People's capacity had been considered when such choices had been made and their right to take informed risks was respected. Managers and staff shared a positive, person-centred approach to the management of risk. Although the person was at the centre of the assessments of risk, there was a residual approach of being over cautious. Managers told us this was a work in progress, and ongoing learning for managers. We observed staff carefully listening to people and offering gentle guidance when appropriate. For example, a person went into the kitchen to get a drink, staff supported them at a discreet distance with encouragement that meant the person was able to carry out the task independently but with staff ensuring they were safe in the kitchen. Processes were in place to record and audit incidents which led to the identification of trends and actions were put in place to mitigate the risks.

People spoke positively about the building and their bedrooms in particular. People had individual plans in place to aid their evacuation in the event of fire. These were specific to the needs of each person. People and relatives told us there had been some redecoration in the past year and this had further improved the environment. Staff had received fire awareness training and understood the actions they should take should a fire occur. Staff were clear about the regular safety checks to be carried out. One staff showed us the food checks carried out in the kitchen. Staff told us they participated in regular training around all aspects of environmental safety. Records confirmed staff training. People were at ease in the service. Staff used equipment appropriately to promote people's safety, for example they carried out visual checks before using moving equipment, such as wheelchairs. We did observe a step ladder being used by staff, which did not have a risk assessment in place. This was raised with the registered manager and immediately addressed. Systems were in place to identify and manage foreseeable environment risks within the service. This meant people, visitors and staff were effectively protected from the risk of harm. Equipment was monitored and maintained according to a schedule. In addition, gas, electricity and electrical appliances were checked and serviced regularly. Fire safety risks had been assessed by a specialist and where necessary action taken to ensure the environment was safe.

People told us there were enough staff. People felt confident staff would listen to them and were trained to carry out their role. One person said, “Staff are alright. They help me.” We observed staff were engaging with people in a positive and friendly way. We saw staff taking time to sit with people and hold conversations, staff were attentive to people's needs. Staff were using communication methods which supported people’s ability to take part in conversations. Managers and staff described a clear induction and training process. The registered manager had oversight of staff training and compliance. Staff we spoke with were positive about the training and support they received from the provider. They knew where to find information and how to seek further guidance, if needed. One staff member said, “I want to learn, it’s really good training. PBS [Positive behaviour support training] has helped me to better understand how to help people have a better life.” Recruitment processes were in place. Checks were carried out as required and these included police and criminal records checks, right to work checks and references were obtained and verified. Training records showed staff completed a wide range of core training, including Safeguarding, First Aid, Equality and Diversity, Health and Safety, Manual Handling etc. More specific training, tailored to the needs of those at the service, was also provided. For example, training in epilepsy, learning disability and autistic spectrum conditions. Communication support and equality.

People and relatives were happy with the cleanliness of the home. Staff had received training in food hygiene and infection prevention and control. Staff understood the guidance for the use of personal protective equipment and told us there was enough to meet the needs of the support they delivered. The home was clean, and the provider was promoting safety through the hygiene practices of the premises with staff completing regular cleaning in accordance with schedules and need. There were practices in place to support people who were not keen on keeping their own rooms clean or having staff clean them. Appropriate arrangements were in place to control the risk of infection.

People received their medicines as prescribed, and they could have 'as required' (PRN) medicines when needed. Some people told us how they liked to receive their medicines, and we saw staff supporting people to receive their medicines in line with their wishes and guidance recorded in their support plans. Staff had been trained to administer medicines and had been assessed as competent to do so safely. The provider's procedure ensured this was reassessed at least yearly using a formal approach. Guidance was in place to help staff understand when to give people their medicines and in what dose. Staff were able to give detailed information about the medicines people took and what they were for. For example, a staff member described the protocol for giving medicine to a person who preferred to receive their medicine in a certain way. Suitable arrangements were in place for obtaining, storing, administering, recording, disposing safely of unused medicines and for auditing of medicines systems. The provider undertook a review of the procedures for recording daily stocks of medicines. Systems were in place to ensure when additional medicines, such as antibiotics were prescribed, these were obtained promptly meaning there were no delays in commencement of administration. Audits of medicines were undertaken to identify any discrepancies with stock levels and ensure records of administration were fully completed. When issues happened, prompt and appropriate actions were taken to mitigate any risk and address the underlaying cause to reduce re occurrence. Incidents were reported to external agencies and families were informed. These incidents were infrequent.