Sunnyview House

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

During our assessment of this key question, we identified a breach of the regulations. We found risk assessments were not always accurate or reflective of people’s assessed needs and lacked detail to guide safe practice. The provider did not have safe, effective systems or processes in place to monitor, review and manage risks to people. The provider failed to implement observational checks for competency with moving and handling techniques and in person centred care giving. During our assessment we observed staff using incorrect moving and handling techniques. Systems to manage medicines safely were not always effective. People were not being effectively safeguarded from potential risk as incidents were not always reported and systems in place for monitoring, recording and reviewing incidents such as unexplained bruising were not robust. The environment was not being carefully monitored and as a result risks to people from the environment were present. People and relatives gave us mixed feedback about staffing levels. Staff felt appreciated and recognised for their work. However, some staff failed to show the required knowledge and understanding of their main responsibilities. Staff were not consistently adhering to the infection prevention and control policy and failed to implement appropriate practices on some occasions.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives were informed when things had gone wrong, however, they were not always informed of clear actions or lessons learned as a result of not always having a thorough investigation completed. This affected people's experience of how the service handled shortfalls, near misses, complaints and therefore people and relatives were not clear on lessons learned.

Whilst leaders told us the importance of the governance systems for reviewing, auditing and learning purposes we failed to see clear evidence of these being effectively implemented consistently. The systems were in place to allow for this to be implemented but actions had not always been followed through to show lessons learned.

Despite having processes and systems in place, the provider did not have robust evidence of lessons learned. Where investigations were required to ascertain causes to injuries, these were not always comprehensively completed, meaning true reflection and evaluation on practices could not take place. For example, where incidents of physical altercations had taken place with a root cause being due to the resident living with a urinary track infection at the time, no action was taken to update the person’s care plan to provide staff with information or further guidance to mitigate future risks to people.

People had their needs assessed prior to admission and were involved in decision making around initial care needs and requirements.

Staff and leaders were able to provide details of pre assessment processes and the benefits of having robust systems in place for new admissions. Staff told us whenever there was anyone new they were informed prior to their admission and information on their initial needs was shared.

We did not receive any feedback from external partners on the systems and processes the provider implemented prior to admissions.

The provider had effective systems in place to assess the needs of people prior to admission to the service. The pre admission process is robust and contributed to the timely completion of a care plan for new admissions.

Most people and relatives told us they thought people were safe at the service. Comments included, "Everything is alright, and I know [name of relative] is safe because of the interaction of staff" and, "I feel safe as there are people around." and, "I feel [name of relative] is safe as they do look after them."[Name of relative] is safe and they are very caring." However, the evidence we collected onsite contradicted the feedback provided and we are not assured people were experiencing risk free care or have been fully safeguarded from avoidable risk or harm.

Staff told us they received safeguarding training and understood their role in recognising and responding to poor care or abuse. Staff told us policies were available to support their knowledge and practice. However, staff did not always follow the reporting procedure when bruising was identified, and some staff failed to safeguard people through using unsafe moving and handling techniques.

People were not being effectively safeguarded from potential risk. Observations showed staff used incorrect moving and handling techniques and despite having correct staffing levels, were unable to support and meet the needs of one person safely. Staff did not show they had a good understanding of this person's care needs and failed to demonstrate effective de-escalation techniques.

The provider did not have effective systems in place to ensure people were safeguarded from potential harm and abuse. We identified shortfalls in the providers systems for reporting incidents and were not assured full and appropriate investigations into the root cause of unexplained bruising and injury was always implemented. For example, 1 person was observed to have bruising on their hand and fingers, and this had not been reported as an incident. The provider had appropriate systems in place to monitor DoLS applications and their progress and kept trackers up to date. MCA and BID were in place where people were subject to restrictions and the provider complied with the principles of the mental capacity act 2008.

Most people and relatives told us they did not feel involved in how risks to them were managed. Most relatives said risks were normally dealt with although we did receive some comments this had not always been prompt. For example, one relative described the home as being 'reactive' when it came to risks. This was in relation to their relative's reduced appetite for food and fluids. There were also some concerns raised that good standards were not always maintained when supporting people's personal care needs. Equipment was provided to keep people safe and relatives who had seen equipment being used told us it was used safely. However, we found instances where moving and handling by staff had not been carried out safely.

Staff told us they knew about people’s risks including the risk of falls, skin integrity and nutrition and hydration. However, we observed staff using unsafe moving and handling practices. Staff told us information was clearly recorded in people's risk assessments and they received verbal handovers to support this. Staff told us the importance of following people's care plans and being vigilant and responsive to any changes. However, observations gathered during the assessment showed some staff were not aware of how to manage or mitigate some risks to people who presented with behaviours that challenge. For example, one person was in a continued state of aggression and presenting with extremely challenging behaviours towards other people. Staff were struggling to support them safely and struggling to mitigate risks to other people as no clear de-escalation techniques were used by staff.

We observed some kind caring interactions, with people being given time to be supported appropriately and carefully. We saw a good staff presence in communal areas. However, on the second day of assessment we observed some unsafe moving and handling practices being implemented which placed people at increased risk of harm or injury. Further to this we observed staff members were struggling with meeting the complex needs of one service user. This increased the risk to staff, the person and others in the service.

The provider did not have safe, effective systems or processes in place to monitor, review and manage risks to people. We were not assured thorough investigations were completed where bruising was identified on people, without assumptions being made prior about their root cause. Care plans and risk assessments were not always accurate or reflective of people’s assessed needs, and there was a lack of information and guidance provided in these for staff to follow to promote safe care and treatment. For example, one person who had been involved in a physical altercation with another person did not have their care plan or risk assessment updated to reflect how staff could mitigate this risk in the future to prevent further incidents. Repositioning records were not consistent and did not show compliance with the assessed needs in people’s care plans or risk assessments. The environment was not being carefully monitored and as a result risks to people from the environment were present. For example, two bedroom doors had holes in and there were sharp edges of the wood sticking out which was brought to the managers attention due to the risk of possible injury to people. Hoists and equipment were stored at both ends of the ground floor unit. This was on both days of assessment and therefore there was an ongoing and continued risk posed to people who were able to mobilise.

People told us on the whole they were happy with their environment, liked their bedrooms and had the equipment they required to meet their needs. Despite this we observed risk in the environment which had not been assessed or managed appropriately, which affects the safety of people in the home.

Staff were unaware of the risks posed to people by the moving and handling equipment being stored in the corridors. Leaders had acknowledged this was a risk but had failed to act on this timely to find a suitable solution.

Despite the environment being clean and well kept, homely and warm it was not always safe for people. Known risks such as incorrect storage of hoists and other equipment was not addressed and continued to be a risk throughout the onsite assessment days. On first entering the building we observed several areas of the home that were unsafe. Items of furniture being stored in corridors across from people's bedrooms and the sluice and equipment door was unlocked. We did recommend the provider finds alternative storage solutions for equipment such as hoists, wheelchairs and crash mats as these were originally being stored in corridors. However, on day 2 of the onsite assessment this had not been rectified and the storage issues continued.

The provider did have good systems and processes in place to ensure all premises and equipment safety checks were completed timely. However, the provider did not always ensure the environment was safe for people living in the home. Despite completing audits and daily walk arounds, shortfalls were still identified on inspection which had not been identified or rectified prior. The daily walk arounds identified some of the shortfalls we found on inspection, such as sluice not being locked, hoists being stored incorrectly, however no action had been taken to address these risks.

People and relatives gave us mixed feedback about staffing levels. We received several comments about staffing levels at weekends being lower. Relatives also told us they had to wait at the door for longer for staff to open and allow access. Relatives also commented about the high number of agency staff, frequent turnover of staff and lack of consistent staff. They felt this impacted on the quality of care and support their relative received. Comments included, "There is a lack of consistent care staff which means less attention to detail. There is a high staff turnover." and "There are not enough staff, they have too much work, they are overloaded” and, "There have been massive changes of staff in the last 2 months, and they are using a lot of agency staff especially at weekends. There are a few regulars but the nurse on the floor now is agency. This means there is a lack of consistency because agency staff don’t know people." We also received mixed feedback on how well trained staff were and one relative commented, "They need training in person centred care."

Staff told us there were enough staff on duty to keep people safe. Where staffing levels changed due to emergencies the provider was responsive in finding suitable cover. One staff member told us they had recently requested an additional staff member on the unit they worked on in the home and this was now in place. Staff told us they had the training, support and supervision to be able to carry out their role safely. Training was carried out via a combination of face to face training and the provider's training App. Staff felt appreciated and recognised for their work. However, when speaking with some staff onsite they failed to show the required knowledge and understanding of their main responsibilities.

People were not being effectively safeguarded from potential risk. Observations showed staff used incorrect moving and handling techniques and despite having correct staffing levels, were unable to support and meet the needs of one person safely. Staff did not show they had a good understanding of this person's care needs and failed to demonstrate effective de-escalation techniques.

The provider safely recruited staff and staff were trained and had supervisions completed. The provider had failed to implement observational checks for competency with moving and handling techniques and in person centred care giving, despite this being noted as a lesson learnt from the action plan on September 2024 quality metric audit. As a result of this, staff were able to continue practicing unsafe moving and handling techniques, and staff struggled to meet the care needs of one person. The heightened needs of one person put a strain on the staffing levels on the unit and it was questionable as to whether the staffing was accurate due to the persons increased needs.

People and relatives were not aware of the infection prevention and control (IPC) issues we had identified with staff practices. People were in receipt of some meals and administration of medication with care staff not following correct procedures and washing their hands prior to commencing these tasks after supporting with mobilising and personal cares. People were therefore at increased risk of infection due to contamination.

Some staff had not followed safe infection prevention and control practices and were unaware of its importance during certain tasks.

The home was well stocked with personal protective equipment (PPE) and had handwashing stations around the home, and it was clean and maintained. However, we did observe staff were not consistently adhering to the infection prevention and control policy and failed to implement appropriate practices on some occasions. For example, staff members failed to wash their hands prior to putting on PPE to serve food at lunch time.

Audits were in place and completed regularly on IPC practices and they did identify some shortfalls in practices. However, all tasks were signed as completed but we were not assured this has been effectively monitored and embedded as some of the issues were still identified on inspection.

We observed people received the medication they required without delays or gaps in administration. Staff administered medication in people's preferred way, and staff were patient with people during this process. However, staff were not always adhering to best practices relating to hand hygiene and infection prevention and control during administration. We observed staff not washing their hands prior to medication administration.

Staff did not always follow safe practices and processes for administering medication safely to people, and some staff were unable to provide confirmation as to why safety protocols should be in place, such as locking the medication trolley between administration.

Medicines were not being managed safely. Medication trolleys and laptops were not always locked when not in use. Medication administration records (MAR)’s and PRN (as required medicine) protocols were not always sufficiently detailed or accurate. For example, 1 person should have been prescribed liquid medication following a change in September 2024 however, this was not reflected on the MAR and stated to give dispersible medication which was not correct. We observed one staff member signing for a medication that they had not seen being administered. This is not as per protocol or requirement. Topical preparations were not being safely managed by staff and there were no risk assessments in place for highly flammable creams which were stored in people's bedrooms. We observed 4 creams had been opened and not dated by staff. Of the four creams reviewed, staff were unable to demonstrate on the MAR when these were opened or by whom. Despite having monthly audits completed which showed a low compliance percentage, actions had not been taken to appropriately address the issues and embed better practice.