CQC report explained · a residential care home
What the CQC found at Sandgate Manor
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, April 2023
Sandgate Manor was rated Requires Improvement; it had improved since an Inadequate rating, but safety, care plans and management systems still had serious gaps.
This was an unannounced follow-up inspection on 24 and 27 January 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicine, staffing and management records.
The home had improved in several areas. Staffing levels, recruitment, safeguarding, activities, communication and partnership working were better. People also experienced more respectful interactions with staff and managers.
However, care plans and risk assessments were not always up to date or detailed enough. Audits had not found or fixed some problems, including missed weight monitoring, incomplete records and gaps in medicine checks. People were not always supported to build independence or work towards their goals.
All five areas were rated Requires Improvement. The home had previously been rated Inadequate and had been in Special Measures. It is no longer in Special Measures, but it remained in breach of Regulations 10, 12 and 17.
Improved staffing
Staffing was based on people's assessed support hours, and people, relatives and staff said staffing levels had improved. Recruitment checks were also completed before staff started work.
“At this inspection, improvements had been made, staff were recruited safely.” from the report
Respectful interactions
Inspectors saw many positive interactions. Staff explained what they were doing, sought permission and supported people in a polite and meaningful way.
“We saw many positive interactions between people, managers and staff.” from the report
Safeguarding improved
Safeguarding concerns were investigated and reported to the local authority when required. Staff had safeguarding training and knew how to raise concerns.
“Where safeguarding incidents had occurred, they had been investigated and reported to the local authority as required.” from the report
More activities
People had more opportunities to take part in activities and go out with one-to-one support. The manager was reviewing staffing patterns to support longer outings.
“At this inspection there were more things for people to do and staff were making improvements.” from the report
Approachable management
The new management team was visible in the main building. This improved communication and gave managers better oversight of staff practice.
“The new management team were visible in the service and approachable.” from the report
Risk information was incomplete
seriousCare plans and risk assessments did not always give staff enough detail about self-harm, moving equipment, asthma, choking and other risks. The provider remained in breach of Regulation 12.
“The provider had failed to ensure they were doing all that is reasonably practicable to mitigate risks to people.” from the report
Records and audits were unreliable
seriousAudits had not identified some missed checks and incomplete records. Care plans and risk assessments were not consistently reviewed or updated, and the provider remained in breach of Regulation 17.
“Governance processes continued to need improvement.” from the report
Independence was not planned
seriousPeople did not always have plans to help them develop daily living skills, prepare for more independent living or achieve their goals. The provider remained in breach of Regulation 10.
“There were no plans in place to support people to prepare to live more independently.” from the report
Health monitoring gaps
needs fixingOne person's weight had not been recorded since October 2022 despite a monthly monitoring plan. Some oral care and end of life plans also lacked important information.
“There was no recorded weight for this person since October 2022.” from the report
Laundry and privacy concerns
minorSome people still received clothes belonging to others. Some people also said staff did not always knock before entering their rooms.
“Sometimes I get the wrong clothes. I don't have labels in my clothes.” from the report
- 01How have you updated each person's risk assessments and care plans since this inspection, especially for self-harm, choking, epilepsy and moving equipment?
- 02How do you now check that weights, continence support, medicines and other health monitoring are recorded on time?
- 03What individual plans are in place to help my relative build daily living skills, become more independent and achieve their goals?
- 04Have all staff completed the training and competency checks needed for epilepsy, emergency seizure medicines and gastrostomy tube support?
- 05What changes have been made to make the home accessible, assess equality and sensory needs, and improve privacy and laundry arrangements?
This was an unannounced follow-up inspection covering all five key questions and checking action from the previous inspection; the home was also checked for infection prevention and control. This explanation was written from the published report of 13 April 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 2022
Rated Inadequate and placed in special measures; inspectors found serious shortfalls in safety, staffing, dignity, personalised care and management.
This was an unannounced inspection on 13, 15 and 30 June 2022. Inspectors spoke with people, relatives and staff, observed care, and reviewed care, medicine, staff and management records.
The home supported 21 people with learning disabilities, autism and physical disabilities. Inspectors found people were not always safe, treated with dignity, involved in their care or supported to make choices and live meaningful lives. There were not enough suitably skilled staff, and risks such as choking, epilepsy, gastrostomy tubes, fire safety and safeguarding concerns were not managed reliably.
All five areas were rated Inadequate: Safe, Effective, Caring, Responsive and Well-led. The overall rating fell from Good at the previous inspection, published on 31 July 2019. The home was placed in special measures and the provider was required to submit an action plan.
Infection control
Inspectors found that infection prevention arrangements were effective overall. The premises were clean and hygienic, and visits were supported in line with guidance.
“The service used effective infection, prevention and control measures to keep people safe, and staff supported people to follow them.” from the report
Medicine administration
Medicines were stored securely and people received them as prescribed. Medicine administration records were complete and accurate.
“People received their medicines as prescribed. Medicines Medicine administration records (MARs) were complete and accurate.” from the report
Communication support
Although some communication records were limited, staff generally understood how people communicated and when they were trying to express something.
“However, staff had good awareness and understanding of individuals' communication needs, they knew how to facilitate communication and when people were trying to tell them something.” from the report
Family contact
People were supported to see relatives and speak with them when they wanted to.
“People were supported to see their relatives and speak to them when they wanted to do so.” from the report
Safety risks and safeguarding
seriousPotential abuse, unexplained injuries and incidents between people were not always investigated or reported. Risk information was incomplete, including for choking, epilepsy, asthma, gastrostomy tubes and fire emergencies.
“People were not protected from the risk of abuse.” from the report
Staffing and recruitment
seriousThere were not enough staff to provide assessed one-to-one support, activities or timely assistance. The staff files reviewed also did not contain full employment histories.
“The provider had failed to ensure there were sufficient numbers staff deployed.” from the report
Dignity and independence
seriousPeople were not consistently treated respectfully or supported to do things for themselves. Privacy was not always protected, and some people were restricted from using areas such as the kitchen without proper assessment.
“People were not supported to increase or maintain their independence.” from the report
Personalised care and activities
seriousPeople were not sufficiently involved in care planning. Their goals, preferences and activity choices were not recorded or acted on, and support sometimes followed fixed routines rather than people's needs.
“People told us they were not involved in developing their own care plans.” from the report
Health support
needs fixingSome people were not supported to make healthy food choices, manage oral health or obtain appropriate health referrals. Staff training and health action plans were also incomplete.
“People were not well supported to manage risks to their teeth and oral care.” from the report
Management and complaints
seriousQuality systems did not reliably identify or correct problems. Complaints were sometimes not recorded or resolved, and care records were unclear, incomplete or not securely stored.
“The provider had failed to assess, monitor and improve the quality and safety of the service.” from the report
- 01How many staff are on duty now, and how do you make sure each person's assessed one-to-one support is provided?
- 02What new risk assessments and procedures are now in place for choking, epilepsy, gastrostomy tubes, safeguarding and fire emergencies?
- 03How are people now involved in writing and reviewing their care plans, goals, activities and independence plans?
- 04How do you record, investigate and resolve complaints, including concerns about missing or mixed-up clothing?
- 05What training and competency checks have staff completed for autism, learning disability support, epilepsy, emergency medicines and oral care?
The inspection began as a focused review of Safe and Well-led after concerns were received, then widened to cover all five key questions; infection prevention and control was also reviewed. This explanation was written from the published report of 24 August 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.
Every inspection of Sandgate Manor
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- July 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2018
Registered with the Care Quality Commission on 3 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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