CQC report explained · a residential care home
What the CQC found at Sapphire House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2021
Rated Requires Improvement; inspectors found safe care, but management checks and some notifications were not yet reliable.
This was an unannounced focused inspection on 28 October 2021. Two inspectors spoke with people, managers, relatives, staff and health professionals. They reviewed care records, medicines records and management documents.
The home was rated Good for Safe. Inspectors found suitable risk plans, enough staff, safe recruitment, secure medicines arrangements and good infection control. Staff supported people with personalised positive behaviour plans and worked with health professionals.
The home was rated Requires Improvement for Well-led. New managers had improved the service, but some audits and governance systems were still being put in place. Some policies and risk assessments needed updating, and not all potential safeguarding incidents had been notified to CQC.
The overall rating was Requires Improvement. This was an improvement from Inadequate at the previous inspection, and the provider was no longer in breach of the regulations identified previously. The inspection only assessed Safe and Well-led.
Personalised support
Care records were clear and individualised. Positive behaviour support plans helped staff understand people's needs and supported more chosen social and leisure activities.
“People's care records were person centred, up to date and easy for staff to understand.” from the report
Safe staffing
Inspectors found enough staff to meet people's needs. Recruitment checks and induction arrangements were described as robust, although recruitment was still continuing.
“The registered manager had recruited new staff who had suitable experience and knowledge to meet the needs of the people who lived at the service.” from the report
Safe medicines
Staff were trained and assessed as competent to give medicines. Medicines were stored securely and reviewed through regular audits.
“Medicines were stored securely and regularly audited by the deputy manager to ensure they were being managed safely.” from the report
Working with health professionals
The home worked with health and social care professionals to review support plans and improve healthcare outcomes.
“The registered manager and staff worked closely with health care professionals such as social workers, community learning disability nurses and the GP to ensure that people received effective healthcare support.” from the report
Incomplete management checks
needs fixingNot all governance systems and oversight audits were in place. This meant the management team still needed to strengthen how it checked quality and safety.
“At this inspection we found not all the governance systems were in place with audits which gave oversight not being completed.” from the report
Policies and risk assessments needed updating
needs fixingSome documents did not yet reflect current guidance. The provider was still embedding the new management arrangements.
“Some policies and risk assessments needed updating to reflect current guidance.” from the report
Safeguarding notifications
needs fixingThe manager notified CQC about safeguarding referrals, but not about some incidents where a referral was made and was not taken forward as safeguarding. CQC recommended that this process be reviewed.
“However, when a referral to safeguarding was made and this was not taken forward as a safeguarding, they did not notify CQC of these incidents, although they were recorded on their safeguarding log.” from the report
- 01Which governance audits were incomplete at the inspection, and are they now being completed regularly?
- 02Have all policies and risk assessments been updated to reflect current guidance?
- 03How do you now decide whether a safeguarding incident must be notified to CQC?
- 04How many permanent staff vacancies remain, and how often are agency staff being used?
- 05What improvements have been made since the new management team took over?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not assessed in this report. This explanation was written from the published report of 15 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, April 2021
Rated Inadequate and placed in special measures; inspectors found serious safety, staffing and leadership failures.
This was an unannounced focused inspection after concerns from two whistle-blowers. Inspectors visited on 26 and 27 January and 1 February 2021. They spoke with people, relatives, staff and professionals, and checked care, medicine and management records.
The home was rated Inadequate for Safe and Well-led. Inspectors found incomplete risk guidance, unsafe staffing levels, poor cleanliness and infection control, and risks in the garden. They also found that management systems had not identified or corrected important problems.
The home had improved some areas since the previous inspection, including fire safety and staff training. A new manager and deputy manager had begun work, but inspectors said significant further improvement was needed. The overall rating fell from Requires Improvement to Inadequate.
New management identified problems
The new manager and deputy manager understood that major improvements were needed and had started reviewing care plans, risk assessments and staff practice.
“Both had identified that systems had not been effective and there were a lot of improvements to be made to ensure people and staff were safe.” from the report
Some medicine controls worked
Medicine storage, disposal and recording arrangements were suitable. Regular audits were being carried out.
“There were suitable arrangements for receiving, storing and disposal of medicines, including medicines requiring extra security.” from the report
Safe recruitment checks
Records showed that staff had been checked through the Disclosure and Barring Service before starting work.
“Staff continued to be recruited safely, and records showed that staff were vetted for their suitability to work with vulnerable people” from the report
Some positive support
Inspectors saw staff supporting some people positively during the visit.
“We observed staff supporting some people in a positive manner during our inspection visit.” from the report
Incomplete risk guidance
seriousRisk assessments and behaviour plans were not always accurate or up to date. This meant staff might not have had the right guidance to keep people safe.
“Risks assessments were in place for people in relation to diabetes, medicines, and behavioural management. However, these required updating as some information was lacking or inaccurate.” from the report
Unsafe staffing levels
seriousRotas did not always provide enough staff. Some staff worked a night shift followed by a day shift, which inspectors said was not safe practice.
“Rotas showed that there had not always been sufficient staffing in place, which posed a risk to staff and people.” from the report
Poor infection control
seriousThe home was not clean, used protective equipment was not always disposed of safely, and shared toilets were not cleaned between use. These failings increased the risk of COVID-19 transmission.
“The service was not ensuring that used Personal Protective Equipment (PPE) was disposed of safely to prevent the spread of COVID-19” from the report
Weak management oversight
seriousQuality checks did not identify important failures, and staff work was not properly checked. The provider had also failed to report a serious injury to the regulator.
“Breaches of regulation we found at this inspection demonstrated that systems to assess and monitor the service were not sufficiently robust.” from the report
Incidents between residents
seriousThe needs of people living in the home were not sufficiently compatible, and incidents had occurred between people. One person was injured after an altercation with another person.
“The incompatibility of the people who lived in the service had led to incidents occurring between people.” from the report
Unclear emergency medicines guidance
needs fixingCare plans and management instructions differed about whether emergency seizure medicine should be given. Records needed to be clearer to prevent confusion.
“Records needed to be clear to prevent any confusion.” from the report
- 01What evidence can you show that staffing levels are now sufficient on every shift, including overnight?
- 02Have all care plans and risk assessments been reviewed and updated, especially those about behaviour, diabetes and medicines?
- 03What changes have been made to cleaning, PPE disposal and shared toilet cleaning since the inspection?
- 04How are incidents between residents now prevented, recorded and reviewed?
- 05What progress has been made in response to the Warning Notice and the home's special measures status?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were not inspected and previous ratings were carried forward. This explanation was written from the published report of 16 April 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 Sapphire House
3 rated inspections over 3 years: the service has held its Requires improvement rating throughout.
- December 2021Requires improvementcurrent ratingup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- April 2019Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2017
Registered with the Care Quality Commission on 3 October 2017.
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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13 live-in carers within about an hour of Norfolk
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 £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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.