CQC report explained · a residential care home
What the CQC found at Island Sands Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
Little Oyster Residential Home is rated Requires Improvement; care had improved, but fire safety checks and records were not always reliable.
Inspectors visited without notice on 21 and 26 September 2023. They spoke with 9 people and 14 staff, observed care, and checked care plans, medicine records, risk assessments, staff files and management records.
The home had improved since earlier inspections. Effective, caring and responsive care were rated Good. People were treated with dignity, supported to make choices, helped to access health care and supported with activities and relationships.
Safe and well-led were rated Requires Improvement. Fire call point checks had missed the flats and bungalows, some medicine records and disposal arrangements needed improvement, and some care, meal and repositioning records were inconsistent. The home was no longer in breach of regulations at this inspection, but CQC said further improvement was needed.
Improved care planning
Care plans contained clearer information about people's needs, preferences and choices. Staff said the plans helped them provide care.
“Care plans were detailed to evidence people's care and support needs.” from the report
Kind and respectful care
Inspectors saw respectful communication, privacy during personal care and support for people to make choices and remain independent.
“We observed good interactions between staff and people, which showed that staff knew people well, knew how to communicate with them.” from the report
Health and nutrition support
People were supported to attend health appointments. Staff monitored weight, fluids and constipation, and provided prescribed meal supplements.
“Records showed people had been supported with medical appointments, dentist appointments and chiropody.” from the report
Enough staff
The dependency tool was used to plan staffing, and planned shifts were filled. Inspectors found enough staff to meet people's needs.
“There continued to be enough staff deployed to meet people's needs.” from the report
Better management systems
A new manager and management structure had brought in more meetings, handovers, audits and action plans. Staff described the management as supportive and approachable.
“The new care system gave the management team better oversight of the care and support provided” from the report
Fire safety checks
seriousWeekly fire call point tests had not covered occupied flats and bungalows. The issue was raised during the inspection and checks were then arranged.
“Weekly fire call point tests had not included the flats and bungalows, where a person lived.” from the report
Medicine records and disposal
needs fixingThe home did not record why as-needed medicines were used or whether they worked. Certain medicines were also not always disposed of according to national guidance.
“However, there was no process in place to record why PRN medicines were being used or if these had been effective.” from the report
Inconsistent care records
needs fixingSome meal records did not say what people had eaten. One person's repositioning records showed gaps of up to six hours despite a four-hour care plan.
“Records remained an area for improvement.” from the report
Audits missed problems
needs fixingSome audits were not strong enough to identify issues found by inspectors, including the missed fire checks.
“Some audits required reviewing and amending as they were not robust enough to identify the issues captured in the inspection.” from the report
Overdue training
minorThe management team had identified overdue training for some staff. Training dates had been booked, but the issue was still being addressed during the inspection.
“The management team had identified training for some staff that was overdue.” from the report
- 01Have the fire call points in every flat and bungalow now been tested, and how often will these checks be reviewed?
- 02How do you now record why as-needed medicines are given and whether they were effective?
- 03What changes have been made to ensure medicines that are no longer needed are disposed of correctly?
- 04How do managers check that meal records and repositioning records are complete and accurate?
- 05Which staff training was overdue, and has all of it now been completed?
This was an unannounced follow-up inspection covering all five CQC questions, with infection prevention and control also reviewed. This explanation was written from the published report of 2 November 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2023
Rated Requires Improvement after improving from Inadequate; inspectors found safer systems than before, but medicines, safeguarding and records still needed work.
Inspectors made an unannounced focused visit on 26 June 2023. They spoke with people and staff, observed care, and checked care records, medicines, risk assessments, audits and other records.
The home had improved since its last inspection. Staffing levels and recruitment were suitable, people were supported with activities and choices, and infection control arrangements were satisfactory. Staff knew people well and people said they felt safe and liked living there.
Important problems remained. Medicines were not always available or recorded correctly. Some health risk assessments were not detailed enough, safeguarding concerns were still being investigated, and records did not always show that care had been provided.
The overall rating changed from Inadequate to Requires Improvement. The home had been in Special Measures since March 2023, but it is no longer in Special Measures. The home still breached regulations about safe care and treatment, safeguarding and good governance.
Staffing and recruitment
Inspectors found enough staff to meet people's needs. Recruitment checks had been completed, including employment history, references and DBS checks.
“There were enough staff deployed to meet people's needs.” from the report
Activities and choice
People were supported to take part in activities they chose and to pursue interests in the local area. Their rooms were personalised.
“Staff supported people to take part in activities of their choice.” from the report
Mental capacity rights
The home was following the principles of the Mental Capacity Act. Capacity assessments and best interest decisions were in place where needed.
“At this inspection, the provider had made improvements and were no longer in breach of regulation 11.” from the report
Infection control
Inspectors were assured about the home's infection prevention arrangements, including use of protective equipment and managing outbreaks.
“We were assured the provider was responding effectively to risks and signs of infection.” from the report
Medicines
seriousPeople could be left without prescribed medicines or testing equipment. Records sometimes had gaps, incorrect entries or unclear doses, and medicine changes were not always clearly passed to staff.
“Systems in place meant that medicines were not always available to people at the start of a new medicines cycle.” from the report
Safeguarding
seriousPeople were not always protected from abuse or avoidable harm. The local authority was investigating a high number of safeguarding concerns, and some investigations had found abuse had occurred.
“People were not always protected from the risk of abuse.” from the report
Health and choking risks
seriousSome epilepsy and diabetes assessments lacked enough detail. Not all staff, including agency staff, had confirmed they understood updated swallowing and food guidance.
“Not all staff had signed this confirmation and there was no robust mechanism for ensuring staff were informed when needs changed so people remained at risk.” from the report
Incomplete records
needs fixingCare records did not always show that care had been delivered. Food, fluids, oral care, blood sugar checks and epilepsy records were inconsistent.
“Maintaining accurate records remained a concern across the service.” from the report
Information sharing
needs fixingMeetings and daily updates were in place, but important changes to medicines, care needs and risks were not always communicated effectively to staff.
“Despite these meetings, important messages were not always communicated to staff effectively to ensure people's care was safe.” from the report
- 01How do you now make sure each person's medicines and testing equipment are available at the start of every medicines cycle?
- 02How do you check that all permanent and agency staff have read and understood updated choking and swallowing guidance?
- 03What action has been taken in response to the safeguarding concerns investigated by the local authority?
- 04How are changes to medicines, care needs and risks handed over to every member of staff?
- 05How will you make sure care records accurately show food, fluids, oral care, blood sugar checks and epilepsy care?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings were carried over from the last inspection. This explanation was written from the published report of 5 August 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Island Sands Residential Care Home
11 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- November 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Island Sands Residential Care Home →
- August 2023Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Island Sands Residential Care Home →
- March 2023Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2022Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2021Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2021Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- February 2021Requires improvementSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- November 2020Inspected but not ratedSafe: Inspected but not rated
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 14 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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