Background to this inspection
Updated
3 August 2023
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 Health and Social Care Act 2008.
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
The inspection was carried out by 2 inspectors and an Expert by Experience. 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
Sunningdale Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Sunningdale Lodge is a care home [with/without] nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We requested feedback from the local authority. We used all this information to plan our inspection.
During the inspection
We received feedback from 7 people and 2 relatives about their views on the care and support provided. We spoke with 12 staff members, including the registered manager and area manager. We looked at 5 care plans and multiple medicines records. We looked at 3 staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed. We received feedback from 1 visiting professional.
Updated
3 August 2023
About the service
Sunningdale Lodge is a residential home providing personal care and accommodation to 40 people. At the time of our inspection, 36 people were using the service. The home is situated in a residential area in Yeovil. Bedrooms are for single occupancy and are arranged over three floors. A lift and stairs provide access to the floors above ground level.
People’s experience of using this service and what we found
Some areas of medicines management needed to be improved. We received some mixed feedback from staff relating to staffing levels and managers helping out when they felt they were short-staffed. Two people told us they didn’t always received support when they needed it. The service had a tool to determine staffing levels which evidence staffing levels were met, the tool was under review by the provider.
The provider’s systems for sharing learning had not ensured information was acted upon promptly following an incident in another service. Statutory notifications were not always submitted in line with regulation. The systems in place to monitor the quality and safety of the service were not always effective in ensuring shortfalls were identified and addressed.
People, their relatives and staff told us people were safe living at Sunningdale Lodge. Staff knew how to recognise and report abuse. Staff were recruited safely. There were infection prevention control measures in place. Risks to people were assessed and mitigated.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People were happy living at Sunningdale Lodge, we received positive feedback about the service and the staff team. Staff told us they felt supported by the registered manager and deputy manager.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (Published 01 December 2017).
Why we inspected
This inspection was prompted by a review of the information we held about this service.
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.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well led section of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sunningdale Lodge on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to good governance and notification of incidents at this inspection.
Please see the action we have told the provider to take at the end of this report.
We have made a recommendation in relation to the management of medicines.
Follow up
We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.