The Care Quality Commission (CQC) has told Sutton Court in Worthing, West Sussex, to make urgent improvements following an inspection in June.
Sutton Court has now been rated inadequate overall and inadequate for being safe and well-led. It is rated requires improvement for being effective, caring and responsive. It was previously rated good overall and good in all five domains. The service has now been placed in special measures.
Sutton Court is a care home for up to 10 people with a learning disability, or autistic people. The inspection was carried out after CQC was notified about a specific incident of alleged physical abuse which took place at the home. As this incident is currently subject to an ongoing criminal investigation, the inspection did not examine the circumstances of the incident. The initial inspection was targeted in response to risk, but was then expanded to a comprehensive inspection, as further concerns were identified.
Debbie Ivanova, CQC’s deputy chief inspector for people with a learning disability and autistic people said:
“When we inspected Sutton Court recently, we had several serious concerns about the safe care and treatment of people using the service. Although the service had enough staff who knew the people using the service, we found that they did not recognise when they were using restrictive and punitive interventions, such as restraint, segregation and seclusion.
“While our inspectors were on the premises, they witnessed a member of staff verbally abusing people, which led them to report this as a further safeguarding concern. We raised this with the manager, who did not immediately remove the staff member from the building while more detail was collected, or report the incident to the local authority safeguarding team, because it had not been recognised as abuse. We also found that the original safeguarding incident that triggered our inspection had not been reported by staff who witnessed it.
“We also found that people were not always given the correct medicine at the right time and that one person’s epilepsy plan had not been followed. This was very concerning, as some people’s medicines were needed for significant conditions, so if they were not receiving them when they were needed, or medical intervention was not called upon at the appropriate time, that could have a serious detrimental impact on a person’s health.
“Additionally, when we pointed out that wedging fire doors open could lead to a rapid spread of fire, the registered manager admitted that they had already been told that automatic door closures should be fitted but said that ‘they don’t always follow recommendations’. This is completely unacceptable; these recommendations are in place to protect people and keep them safe.
“The provider has now taken some action to mitigate the risks, but this is an ongoing process and we will continue to monitor the service closely, in conjunction with the local authority, to ensure that the required improvements are made. If we are not satisfied that our concerns have been addressed, we will consider what further enforcement action to take.”
Inspectors found the following issues at the service:
- Governance systems did not ensure that people were kept safe and received a high quality of care in line with their individual needs
- The service was not able to demonstrate how it was meeting some of the underpinning principles of right support, right care, right culture
- The ethos, attitudes and behaviours of managers and staff did not always ensure that people were able to lead confident, inclusive and empowered lives
- People were not always protected from abuse and poor care and staff had failed to support safeguarding incidents
- The provider had not ensured that managers and staff had suitable training, skills and knowledge to support people whose behaviour may challenge themselves and others, in the least restrictive and most person-centred way
- Managers and staff did not always understand the policies in place in the service
- The service did not focus on people’s quality of life and the delivery of care was not always tailored to individuals or in their best interests
- Although staff knew people well and often showed kindness, they did not always recognise how to provide a model of care that maximises people's choice, control and independence
- People’s communication needs were not always met, and information was not always shared in a way that people could understand. Autistic people’s sensory needs were not assessed, to ensure that their environment could be adapted to meet their needs
- Medicines were not effectively checked, and errors were not reported. Risk assessments in relation to health and safety were not always carried out.
However:
- Some people who had lived at Sutton Court for many years, said they were generally happy with the support their received
- People said they had a good range of food available to them and they enjoyed the meals
- People said they received appropriate health care support from staff and managers had taken steps to support people who needed it to be more confident when attending health appointments
- People said they had access to independent support and that staff encouraged people to maintain links with people who were important to them.
Full details of the inspection are given in the report published on our website.
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