CQC report explained · a residential care home
What the CQC found at Sandbeck House Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Risks, medicines, staffing, recruitment and infection control were managed safely. Inspectors found the home was clean and staff knew how to report safeguarding concerns.
- Effective?
- Requires improvement
- Training and supervision systems were in place, but some staff did not consistently put their training into practice in moving and handling and infection control.
- Caring?
- Good
- Staff were generally kind and caring, and supported people's dignity, privacy, independence, choices and cultural preferences.
- Responsive?
- Requires improvement
- Care plans were comprehensive and generally reflected people's needs and preferences. However, people did not always receive enough stimulation or social interaction, and staff did not always follow stated preferences.
- Well-led?
- Good
- The new manager provided open, hands-on leadership. Audits and action tracking had been strengthened, and the provider had addressed the five previous regulatory breaches.
What inspectors found, December 2021
Rated Requires Improvement; inspectors found safe, kind care and strong recent progress, but activities and consistent person-centred care still need improvement.
Inspectors visited unannounced on 3 and 10 November 2021. They spoke with people living in the home, relatives and staff. They reviewed care records, recruitment files, audits and other information.
The home was rated Good for Safe, Caring and Well-led. Staff were kind, medicines and risks were managed safely, and the new manager had introduced stronger checks and improvements.
Effective and Responsive were rated Requires Improvement. Inspectors found that some staff did not always follow their training, and people did not always receive enough stimulation, social contact or activities.
The previous rating was Inadequate, with five breaches of regulations. Inspectors found these breaches had been addressed. The home was no longer Inadequate or in Special Measures, but the overall rating remained Requires Improvement.
Safer care
Inspectors found that risks, medicines, staffing, recruitment and infection control were being managed safely. Improvements had also been made to the building and equipment.
“Systems were in place to assess and manage potential risks to people's safety and welfare, including risks related to nutrition, skin care and mobility.” from the report
Kind and respectful staff
Staff generally treated people warmly and supported their dignity, privacy, independence and choices.
“Almost everyone we spoke with told us staff were kind and caring in their approach.” from the report
Improved care planning
Care plans were comprehensive, regularly reviewed and usually gave staff useful information about people's wishes and needs.
“We reviewed a selection of care plans and found they were comprehensive and well-maintained, with generally detailed descriptions of people's wishes and requirements.” from the report
Stronger leadership
The new manager had introduced better quality checks and responded openly to feedback. All five breaches from the previous inspection had been addressed.
“A suite of audits was now in place to monitor and improve the quality of the service.” from the report
Training was not always followed
needs fixingSome isolated incidents showed staff did not consistently put their training into practice in moving and handling and infection control.
“Further action was required to ensure good practice in all aspects of care provision was embedded and sustained over time.” from the report
Person-centred care was inconsistent
needs fixingOn one occasion, a staff member did not follow a person's recorded preference about how they wished to be addressed.
“Further work was required to ensure these improvements were fully embedded in staff practice.” from the report
Some areas needed refurbishment
minorAlthough improvements had been made, parts of the home still looked tired. Further bedroom and carpet improvements were planned.
“Despite this investment, some parts of the home still looked 'tired' and in need of refurbishment.” from the report
End of life plans were incomplete
needs fixingNot everyone had an end of life care plan. The manager said people and families would be offered the opportunity to create one if they wished.
“Not everyone had an end of life care plan.” from the report
- 01How often are group activities, one-to-one activities and outings now provided, and how do you record who takes part?
- 02What checks show that staff consistently follow their moving and handling and infection control training?
- 03How do you make sure staff follow each person's recorded preferences, including how they wish to be addressed?
- 04Has the minibus been repaired or replaced, and what community outings are currently available?
- 05Does every resident now have the opportunity to make an end of life care plan if they wish?
This was an unannounced planned inspection of all five key questions, including infection prevention and control under Safe, following the previous Inadequate rating. This explanation was written from the published report of 2 December 2021 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, March 2021
Rated Inadequate and placed in special measures; inspectors found serious risks to safety, weak management and repeated failures to improve.
This was an unannounced, focused inspection on 9 and 14 December 2020. Inspectors spoke with people living in the home, relatives, staff and managers. They reviewed care records, staff recruitment files, medicines information and quality checks.
The home was not safe. Inspectors found hazards in the building, poor infection control during a COVID-19 outbreak, gaps in care plans and medicines records, and delays in giving important medicines. Some people were not repositioned as often as their care plans required. The home also did not learn properly from serious incidents.
The home was not well-led. Audits had not been completed for several months, the manager had too much responsibility without enough support, and required notifications had not been sent to CQC. Staff recruitment was safe and staff morale was generally good, but the overall rating fell from Requires Improvement to Inadequate because there had not been enough improvement since the previous inspection.
Safe recruitment
The necessary checks had been completed for recent recruitment decisions, helping to show that staff were suitable to work with residents.
“We reviewed recent recruitment decisions and saw that the necessary checks had been carried out to ensure that the staff employed were suitable to work with the people who used the service.” from the report
Staff morale
Staff were generally positive about their work and said the team was working well together.
“We've got a good team at the moment and morale is quite good.” from the report
Action after feedback
The provider responded positively to inspectors' feedback and corrected many of the health and safety hazards by the second inspection day.
“During and after the inspection, the nominated individual responded positively to our feedback and took immediate action to address many of the issues of concern we identified.” from the report
People were at risk of harm
seriousInspectors found many hazards, including unsafe fire and electrical arrangements, chemicals that could be accessed, unsuitable stair gates and poor moving and handling practice.
“This meant people were not safe and were at risk of avoidable harm.” from the report
Medicines were not managed safely
seriousOne person went without antibiotics for three days. Medicines records had gaps, and a trained senior member of staff was not always available at night.
“These errors had gone undetected by staff until highlighted by our inspector.” from the report
Care plans were incomplete
seriousOne person had lived in the home for more than two months without a care plan or individual risk assessment. Other reviews had not been completed for several months.
“There were still significant shortfalls in the care planning system and the provider was still failing to maintain full compliance with the Mental Capacity Act (2005).” from the report
Weak management oversight
seriousThe manager was covering too much work without a deputy or administrator. Important audits had not been completed for several months, so risks were not identified quickly.
“The provider had failed to assess, monitor and mitigate a wide range of risks to people's safety in areas including premises and equipment; infection prevention and control and medicines.” from the report
Legal notifications were missed
seriousThe provider did not notify CQC about six safeguarding allegations or at least seven Deprivation of Liberty Safeguards authorisations.
“The provider had failed to notify us of any of these allegations, as required in law.” from the report
- 01What has been done to remove the building and equipment hazards identified by inspectors, and how are these checks recorded now?
- 02How do you ensure that a medicines-trained senior staff member is available on every night shift?
- 03How are medicines administration records, medicines storage temperatures and missed doses checked now?
- 04Have every resident's care plans and risk assessments been completed and reviewed at the required intervals?
- 05What changes have been made to management cover, audits and notifications to CQC since this inspection?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from previous comprehensive inspections. This explanation was written from the published report of 31 March 2021 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 Sandbeck House Residential Home
4 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- December 2021Requires improvementcurrent ratingup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
Read what inspectors found at Sandbeck House Residential Home →
- March 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
Read what inspectors found at Sandbeck House Residential Home →
- April 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015
Registered with the Care Quality Commission on 2 June 2015.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.