CQC report explained · a residential care home
What the CQC found at Sandford Road
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People generally received medicines safely and there were enough suitably trained staff. However, medicines incidents were not managed well, some records and guidance were unclear or out of date, and incident monitoring needed improvement.
- Effective?
- Good
- People had care based on their needs, communication preferences and goals. Staff were trained and supported, and people received appropriate help with food, health care and specialist support.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People were involved in everyday choices and care planning, supported to stay independent and helped to keep in touch with family.
- Responsive?
- Good
- The home responded to people's communication, cultural, spiritual and sensory needs. People chose activities and were supported to use local community facilities, and complaints were taken seriously.
- Well-led?
- Requires improvement
- Leaders were approachable and had introduced improvement plans, audits and outside quality checks. However, systems did not reliably identify gaps in medicines, infection control, incident monitoring or care records, leading to a breach of Regulation 17.
What inspectors found, February 2022
Rated Requires Improvement and no longer in special measures; care was kind and person-centred, but medicines records and governance systems were not consistently reliable.
This was an unannounced planned inspection. Inspectors visited the home, spoke with people, relatives and staff, and reviewed care records, medicines records, recruitment files and the systems used to check quality and safety.
People were generally supported with kindness, respect and choice. Inspectors found enough trained staff, person-centred care, suitable activities, good support with health needs and effective involvement of people and families.
The home was not always safe or well-led. Medicines incidents were not always reported or used for learning, some guidance and care records were out of date, and checks on quality, infection control and incidents were not robust enough. The overall rating was Requires Improvement, with Good ratings for Effective, Caring and Responsive.
Kind and respectful care
Staff understood how people communicated and supported them with dignity, privacy and compassion.
“People received kind and compassionate care from staff who protected and respected their privacy and dignity and understood each person's individual needs.” from the report
Choice and independence
People were involved in daily decisions, including meals, activities, personal care and medicines. Staff encouraged people to do things for themselves.
“People were supported to be independent and had control over their own lives. Their human rights were upheld.” from the report
Meaningful activities
People chose activities linked to their interests and short-term goals, both at home and in the community.
“People made choices and took part in meaningful activities which were part of their planned care and support.” from the report
Trained staff
Staff received relevant training, supervision and appraisal. Training included learning disability, autism, mental health needs, human rights and restrictive interventions.
“People received care, support and treatment from trained staff and specialists able to meet their needs and wishes.” from the report
Improvements since the last inspection
The home improved restraint monitoring, recruitment checks and person-centred care plans. It also introduced a service improvement plan and additional audits.
“This service has been in Special Measures since 17 September 2020. During this inspection the provider demonstrated that improvements have been made.” from the report
Medicines incidents and guidance
needs fixingStaff recognised medicines incidents but did not always report them properly or show how lessons were shared. Some readily available medicines guidance was out of date, and one as-required medicine record was unclear.
“The service did not manage medicine incidents well and were unable to show us evidence of sharing lessons learned with the wider team.” from the report
Incomplete and inaccurate records
needs fixingSome care records contained inaccurate or outdated information. Although staff knew people's needs and inspectors found no impact on care, records were not consistently reliable.
“The systems to monitor the accuracy of people's care records had not always been effective.” from the report
Weak quality monitoring
seriousThe home's checks did not reliably identify problems with incidents, medicines, infection control and care records. This was a legal breach of Regulation 17.
“Systems were not robust enough to demonstrate effective monitoring of the quality of the service or ensure complete and accurate records were kept.” from the report
Infection control records
needs fixingThe infection control policy was not up to date. Records of visitor checks were not kept, and one inspector was not asked for COVID-19 test results before entering.
“Records of checks carried out on visitors were not kept. The IPC policy was not up to date nor contained specific consideration of those people living at the home.” from the report
- 01What has changed to make sure medicines incidents are reported, investigated and shared with all staff?
- 02How do you check that medicines guidance and as-required medicine protocols are current?
- 03How will you make sure people's care records are accurate and updated when their needs change?
- 04What action has been taken to improve visitor checks, COVID-19 testing records and the infection control policy?
- 05What progress has been made on the action plan for the Regulation 17 breach, and when will it be reviewed?
This was a planned inspection of the whole care home and all five key questions, including infection prevention and control as part of the Safe assessment. This explanation was written from the published report of 15 February 2022 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, November 2020
Rated Inadequate and placed in special measures; inspectors found serious problems with safeguarding, recruitment, care planning and management oversight.
This focused inspection took place on 15, 16 and 17 July 2020 after concerns about safeguarding, restraint, care, finances and the environment. Inspectors visited the home, spoke with relatives, staff and professionals, and checked care, medicine, recruitment and management records.
The home was not always safe. Records about physical restraint did not always show how long it lasted or what less restrictive steps had been tried. Recruitment checks were incomplete, staff were not following COVID-19 mask guidance, and some fire doors were propped open.
Care plans did not always contain up-to-date information about people's needs or how COVID-19 restrictions affected their routines. Management checks were not effective enough to find or fix these problems. The overall rating fell from Good at the previous inspection to Inadequate.
Medicines
Inspectors found that people received their medicines as prescribed and that staff had medicines training with checks of their competence.
“We reviewed the medicine records which confirmed people received their medicines as prescribed and medicines where stored appropriately.” from the report
Staffing levels
Staff and relatives said there were enough staff to meet people's assessed needs.
“Staff and relatives told us sufficient staff were on duty to meet people's needs.” from the report
New management recognised problems
The new manager accepted the shortfalls and said work was under way to address them.
“They acknowledged the shortfalls we found in the service and advised they were working towards addressing them.” from the report
Use of restraint
seriousRestraint records did not always explain its duration, the steps tried beforehand or staff positions. Managers did not consistently review incidents or look for patterns and triggers.
“This meant it was not clear and transparent if the restraint used was the least restrictive and for the shortest possible time.” from the report
Incomplete recruitment checks
seriousTwo recently recruited staff files lacked evidence that required checks had been completed before employment. Employment histories and references also had gaps or had not been properly validated.
“Neither files contained evidence to support a disclosure and barring check had been completed prior to the staff members commencing employment.” from the report
Care plans not up to date
needs fixingSome support plans did not contain enough detail about people's needs, routines or alternative activities during COVID-19 restrictions.
“People's support plans had not been updated to consider the impact of COVID19 on their needs and daily routines.” from the report
Weak management checks
seriousThe home's audits did not identify or resolve important problems. This included issues with restraint records, care plans, recruitment, finances, medicines records and PPE.
“The lack of governance systems and oversight meant people were at risk of receiving poor quality care.” from the report
COVID-19 precautions
needs fixingStaff were not wearing face masks in line with government guidance, and the home had not completed the required individual risk assessments to explain this.
“Only one member of staff was observed to be wearing a face mask.” from the report
- 01What has changed in the recording, review and analysis of physical restraint since this inspection?
- 02Have all staff recruitment files now been checked for employment histories, references and disclosure and barring checks completed before employment?
- 03How are care plans kept up to date, including people's routines and activities when community activities are unavailable?
- 04What audits are now carried out to identify problems with safeguarding, care plans, finances, medicines and infection control?
- 05What action has been taken about the fire doors, communal flooring, lighting and staff use of PPE?
This was a focused inspection of Safe and Well-led; the other key questions were not inspected and their previous comprehensive inspection ratings were used. This explanation was written from the published report of 19 November 2020 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 Sandford Road
3 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- February 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2020Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- June 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2018
Registered with the Care Quality Commission on 29 May 2018.
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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