CQC report explained · a nursing home
What the CQC found at Sandiacre Court Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm, with systems for risk assessments, equipment checks, safeguarding, medicines and infection control. Some conflicting or outdated documents and gaps in medicine protocols were identified and addressed by the provider.
- Effective?
- Good
- The report did not give a separate rating for this question.
- Caring?
- Good
- The report did not give a separate rating for this question.
- Responsive?
- Good
- The report did not give a separate rating for this question.
- Well-led?
- Good
- Management systems had improved, including maintenance checks, incident reviews and staff meetings. Inspectors still identified areas for continued improvement in daily checks, medicine audits and checking updated care plans.
What inspectors found, August 2022
Rated Good; inspectors found improved safety and leadership, but some records and audit checks still needed attention.
This was an unannounced inspection on 07 June 2022. Two inspectors spoke with people using the home, relatives and staff. They reviewed care records, medicine records, recruitment files and management documents.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found enough suitable staff, medicines were given as prescribed, infection controls were in place and risks were being managed.
The home had improved since its previous Requires Improvement rating in April 2022. It was no longer in breach of the regulations identified at that inspection. The provider also said it had acted immediately on issues found during this inspection.
Up-to-date care records
The electronic care system was current and gave staff guidance about people's needs. People and families were involved in reviewing risks and care plans.
“The electronic care record system in use was kept up to date, this ensured staff had current guidance to follow to meet peoples' needs.” from the report
Enough staff
Inspectors found enough suitable staff on duty. Recruitment checks had been completed before new staff started.
“There were sufficient numbers of suitable staff employed. The number of staff on duty matched the staff rota.” from the report
Safe medicines support
People received medicines as prescribed. Staff were trained and competent, and knew when some as-needed medicines should be offered.
“People received their medicines as prescribed. Systems were in place to manage medicines safely.” from the report
Improved management
The provider had introduced systems to monitor maintenance, incidents and quality. The home was no longer in breach of the regulations found at the previous inspection.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation17.” from the report
Conflicting records
needs fixingSome documents contained information that was conflicting or out of date. The provider acted during the inspection to review and update them.
“Some documents contained conflicting or out of date information.” from the report
As-needed medicine instructions
needs fixingSome PRN, or as-needed, medicine protocols did not contain enough detail to support consistent treatment. The provider reviewed and updated them during the inspection.
“Further detail was required in PRN protocols to ensure consistent management of conditions, for example, constipation.” from the report
Daily checks and audits
needs fixingInspectors identified problems with completing daily safety checks and with the timing of medicine and care-plan audits. The provider gave assurances after the inspection that actions had been put in place.
“timeliness of daily medicine audit checks to identify and address missed medicine errors” from the report
- 01How do you check that care records contain no conflicting or outdated information?
- 02How are PRN medicine protocols kept detailed enough for each person's condition?
- 03How do you make sure daily safety checks are completed on every shift?
- 04How quickly are medicine audits completed when a dose may have been missed?
- 05How do you check that updated care plans have been audited and are consistent?
This inspection reported ratings for Safe and Well-led only; it did not give separate ratings for Effective, Caring or Responsive. This explanation was written from the published report of 10 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.
What inspectors found, April 2022
Sandiacre Court Care Centre was rated Requires Improvement; inspectors found risks around staffing, safeguarding and management, although medicines and the care reported by relatives had strengths.
This was an unannounced inspection on 24 January 2022. Inspectors spoke with people, staff and relatives, and reviewed care records, incident reports, medicines records, staff files and management records. The inspection was prompted by concerns about staffing and people's safety.
The home was not always safe. Inspectors found that some safeguarding incidents had not been reported, risks had not always been reviewed, there were not always enough staff, and some mattresses needed replacing. Training and guidance for supporting people whose behaviour was difficult were also not consistent.
The home was not well-led. Audits and other checks had not reliably identified or dealt with risks. The new manager had been in post for three weeks and was managing a COVID-19 outbreak. Inspectors found strengths in medicines management, infection control measures and relatives' views that staff were kind and responsive.
The overall rating was Requires Improvement. Safe and Well-led were both rated Requires Improvement. The inspection did not review the other three key questions, so their previous ratings were carried forward from the last comprehensive inspection in 2018, when the service was rated Good.
Medicines
Inspectors found that medicines were managed safely. Staff explained medicines and stayed with people until they had taken them.
“Staff took time to explain to people their medicine and stayed with the person until the medicine was taken.” from the report
Kind and responsive staff
Relatives gave positive comments about the care and said staff were kind and responsive.
“Relatives we spoke with said staff were kind and responsive.” from the report
Infection control measures
Inspectors found effective use of protective equipment, testing and arrangements for managing infection outbreaks, although they had some concerns about equipment hygiene.
“We were assured that the provider was using personal protective equipment (PPE) effectively and safely.” from the report
Food and visits
People had a choice of meals and their dietary needs were met. Relatives were also kept informed about COVID-19 guidance and management changes.
“We saw people had a choice of meals and all dietary needs were being met.” from the report
Safeguarding and risk of harm
seriousSome safeguarding incidents had not been reported, and action had not always been taken to protect people from ongoing risks. This was a breach of Regulation 13.
“We found safeguarding incidents which had occurred at the home, which placed people at risk of harm had not been reported, and the ongoing risks to people had not been mitigated.” from the report
Staffing levels
seriousThere were not always enough staff to meet people's needs, and the number of staff present did not match the rota. Domestic staff were sometimes used for care, which affected cleaning.
“There was not always enough staff to support the needs of people.” from the report
Equipment and risk checks
seriousFour mattresses needed immediate replacement and more were replaced after further checks. Inspectors were not assured that equipment checks consistently protected people from harm. This was a breach of Regulation 12.
“We found four mattresses required immediate replacement and following a full check of the mattresses more were replaced.” from the report
Weak management oversight
seriousAudits and maintenance checks had not consistently identified problems or ensured that action was taken. This was a breach of Regulation 17.
“Audits had not been used to drive improvements.” from the report
Training and care guidance
needs fixingNot all staff had received the training needed for their roles. Care plans and guidance were not consistent for people whose behaviour was difficult.
“Staff had not always received the required training when supporting people with behaviours that challenge.” from the report
- 01What staffing levels are now in place, and how do you check that the staff on duty match the rota and meet residents' needs?
- 02How are safeguarding concerns now recorded, reported and reviewed so that ongoing risks are dealt with?
- 03Have all mattresses and other equipment been checked and replaced where needed, and how often are these checks now recorded?
- 04What training have staff completed for safeguarding and for supporting people whose behaviour is difficult?
- 05What action has been completed in response to the Regulation 17 enforcement action, and can we see the improvement plan?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the 2018 comprehensive inspection. This explanation was written from the published report of 27 April 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 Sandiacre Court Care Centre
4 rated inspections over 6 years: the service has held its Good rating throughout.
- August 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- September 2020Inspected but not ratedSafe: Inspected but not rated
- March 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2014
Registered with the Care Quality Commission on 23 December 2014.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
62 live-in carers within about an hour of Derbyshire
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.
Most charge £1,010 to £1,260 a week. 51 can care for a couple. 12 years' experience on average.
“Ernest is an amazing professional carer who delivers care from the heart.”
“We particularly appreciate the companionship Dawn gives in the evenings when she plays cards and Scrabble with my mother.”
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.