CQC report explained · a nursing home
What the CQC found at Sanford House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that infection risks were being managed, including the use of protective equipment, testing, isolation, admissions, hygiene and social distancing.
- Effective?
- Good
- This was a targeted infection prevention and control inspection, so this question was not rated.
- Caring?
- Good
- This question was not assessed or rated in this targeted inspection.
- Responsive?
- Good
- This question was not assessed or rated in this targeted inspection.
- Well-led?
- Good
- This question was not assessed or rated in this targeted inspection.
What inspectors found, December 2020
Sanford House Nursing Home: inspectors found good infection prevention and control, but this targeted visit was not rated.
This was an unannounced, targeted inspection on 2 November 2020. Inspectors checked infection prevention and control because of the CQC's response to coronavirus outbreaks. They spoke with the manager, observed staff practice and reviewed records.
Inspectors were assured that the home was using protective equipment safely, carrying out testing, managing isolation and admissions safely, and following shielding and social distancing rules. They also found suitable signage, hygiene arrangements and an up-to-date infection control policy.
The inspection found some good practice. The manager made improvements within 24 hours about disposing of protective equipment, and the CQC signposted the provider to resources to develop its approach.
The overall service and Safe rating were both recorded as 'Inspected but not rated'. This was not a full inspection of the quality of care, and the report does not give ratings for Effective, Caring, Responsive or Well-led.
Protective equipment
The home had enough protective equipment, and staff had received extra training about infection control and Covid-19.
“Sufficient supply of PPE was held by the service and the staff team had received additional training in relation to infection control and Covid-19.” from the report
Testing and checks
Residents and staff were receiving Covid-19 tests. Staff and residents also had daily temperature checks, while visitors had temperature and oxygen level checks before entering.
“All staff and residents are receiving Covid-19 testing.” from the report
Managing infection risks
The home used isolation for people who tested positive and for new admissions. It also had a system for cleaning surfaces when someone could not fully self-isolate.
“Individuals were required to isolate where they were positive for Covid-19, as well as if they were a new admission to the service.” from the report
Clear guidance
The home displayed infection control signs at the entrance and throughout the building, and the policy was up to date.
“The service had clear infection control signage both at the entrance and throughout the building.” from the report
Disposal of protective equipment
minorInspectors gave feedback about disposal of protective equipment. The manager made improvements within 24 hours, so this was addressed quickly but was still a shortfall identified during the visit.
“Feedback was given during the day of inspection and the manager made improvements within 24 hours of the service visit to further improve practice in relation to the disposal of PPE.” from the report
Further development
minorThe CQC signposted the provider to resources to develop its infection prevention and control approach.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01How are you currently disposing of protective equipment, and what changes were made after the inspection?
- 02How are residents, staff and visitors currently tested or checked for Covid-19 and other infections?
- 03What arrangements are now used for people who test positive or who are newly admitted?
- 04What are the home's current visitor, distancing and remote appointment arrangements?
- 05What were the ratings and findings at the home's last full inspection for Effective, Caring, Responsive and Well-led?
This was an unannounced targeted inspection of infection prevention and control only; the service was inspected but not rated and the other questions were not assessed. This explanation was written from the published report of 24 December 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.
What inspectors found, October 2019
Rated Good; inspectors found safe, kind and personalised care, with minor concerns about cleaning schedules and staff pressure.
This was an unannounced, planned inspection. Inspectors spoke with people using the home, relatives, staff and visiting professionals. They reviewed care records, medicines records, staff files and management records.
The inspectors found people were cared for in a clean and safe environment. There were enough trained staff, medicines were given when needed, and risks were assessed and managed. People received personalised care and support with food, activities, communication and end-of-life wishes.
People and relatives gave very positive feedback about staff. Inspectors saw kind and respectful care. They found the home was well managed, with systems to monitor quality and learn from problems.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. This was unchanged from the previous Good rating, published in February 2017.
Kind and respectful staff
People and relatives spoke very positively about staff. Inspectors saw staff remain calm and supportive, including when someone became distressed.
“We observed staff engaging with people in a calm manner.” from the report
Personalised care
Care plans included people's preferences, interests and life history. Staff supported people to choose how and where they received care.
“Care plans were personalised to meet people's needs.” from the report
Activities and relationships
The home offered a varied programme of activities and supported some people to access the local community. Relatives were encouraged to be involved.
“There was a full and varied programme of activities within the home and some people were also supported to access their local community.” from the report
Good management
Managers were described as open and approachable. The home used audits, meetings and an action log to identify and act on improvements.
“There were systems and processes in place to monitor the quality of care through audits and observation.” from the report
End-of-life support
The home offered advance care planning and trained staff to support people's wishes, comfort and spiritual needs at the end of life.
“The home offered people support to complete an advanced care plan which described how they wanted to be supported at the end of their life, including any specific wishes and spiritual needs.” from the report
Cleaning schedules
minorSome storage areas were not included on the cleaning schedule and were not always clean. The deputy manager said this would be addressed.
“Some of the storage areas were not on the schedule and were not always clean.” from the report
Pressure during staff absences
needs fixingStaff generally said there were enough staff, but some reported extra pressure when colleagues were absent or new staff were still training.
“Some commented that if there was staff absence or when there were new staff still undergoing training this could put additional pressure on staff.” from the report
- 01How do you keep staffing levels safe when there are absences or new staff are still being trained?
- 02Have all storage areas been added to the cleaning schedule, and how is their cleanliness checked?
- 03How would you assess and support my relative's dementia, nursing or end-of-life needs?
- 04How will my relative's food preferences, communication needs and daily choices be recorded and reviewed?
- 05How are relatives involved in care planning and told about changes or serious problems?
This was an unannounced planned inspection covering all five CQC questions; the previous rating was Good, published on 23 February 2017. This explanation was written from the published report of 23 October 2019 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 Sanford House Nursing Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- December 2020Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- October 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 21 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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