CQC report explained · a nursing home
What the CQC found at Saxlingham Hall Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Medicines were managed safely, risks were generally well managed, and infection control arrangements were in place. Inspectors recommended reviewing staffing levels because some people and staff felt there were not always enough staff.
- Effective?
- Good
- People received effective care from competent and knowledgeable staff. Staff worked with health professionals and supported people with eating, drinking and health needs, although some people felt the food did not fully match their preferences.
- Caring?
- Good
- Staff were kind, respectful and knew people well. However, some feedback suggested that staff could sometimes be task focused and did not always have enough time for social needs.
- Responsive?
- Good
- Staff generally listened to people's preferences and met their needs. Activities had improved, including one-to-one time, but care records were not always up to date or detailed enough to show people's wishes and changing needs.
- Well-led?
- Requires improvement
- The new management team understood what needed to improve, and quality audits were in place. However, formal feedback, care reviews, person-centred records and some incident records were not consistently managed.
What inspectors found, July 2022
Saxlingham Hall Nursing Home was rated Good overall, with kind and safe care, but its leadership and person-centred records required improvement.
Inspectors made an unannounced visit on 14 and 16 June 2022. They spoke with six people, eight relatives, staff and health and social care professionals. They reviewed care records, medicines records, staff records and other documents.
The home was rated Good for Safe, Effective, Caring and Responsive. People were generally safe, received medicines as prescribed, and were supported by kind and knowledgeable staff. Activities and end of life care were also viewed positively.
Well-led was rated Requires Improvement. People and relatives did not always have regular chances to give feedback or review care. Care records were sometimes out of date or did not include enough detail about people's wishes. Inspectors also recommended reviewing staffing levels.
The overall rating had improved from Requires Improvement under the previous provider in 2019. The new management team had only been in place for a few weeks, but inspectors found it understood the main areas needing improvement.
Safe medicines management
People received their medicines as prescribed. Staff had medicine training, their competence was checked, and medicines were stored safely.
“Medicine records showed people had received their medicines as prescribed.” from the report
Kind and respectful staff
People and relatives described staff as kind and respectful. Inspectors found that staff knew people well and protected their dignity and privacy.
“Our observations showed staff treated people respectfully in a way that promoted their dignity and privacy.” from the report
Improved activities
People, relatives and staff spoke positively about the activities programme. The activities co-ordinator also provided one-to-one time for people who preferred to stay in their rooms.
“People, staff, and relative spoke very positively about the difference they had made.” from the report
Good health outcomes
Staff identified and managed health needs effectively. Inspectors found examples of wounds healing and people at risk of malnutrition gaining weight.
“We found people's individual risks had been managed very well and as a result people's quality of life had improved.” from the report
Staffing levels
needs fixingSome people and staff felt there were not always enough staff, and people sometimes had to wait for assistance. Inspectors said this had not significantly affected safety or needs, but recommended a review.
“People also told us they sometimes had to wait for assistance.” from the report
Care records not always current
needs fixingRecords did not always show people's wishes, feelings and risks in enough detail. Some care plans had not been updated when people's needs changed.
“In some cases we found people's care needs had changed but care plans had not been updated to reflect this.” from the report
Limited formal involvement
needs fixingResident and relative meetings had not been held regularly. People and relatives did not always have structured opportunities to discuss care, menus, activities or improvements.
“People living in the service and staff said that they were not regularly asked their opinion on the care provided and what improvements they thought might be needed.” from the report
Incident notification records
needs fixingOne historic incident that should have been reported to the regulator had not been notified. Incident records also did not always show whether people and relatives had been informed.
“Due to changes in the management team we found one historic incident had occurred in the service which we should have been notified of but had not.” from the report
- 01How many staff are normally on each shift, and how do you respond when people have to wait for assistance?
- 02How often are care plans reviewed, and how quickly are they updated when someone's needs or wishes change?
- 03How can residents and relatives give formal feedback about care, menus and activities?
- 04How will you make sure resident and relative meetings are held regularly?
- 05What changes have been made to incident reporting and notification since this inspection?
This was an unannounced inspection covering all five key questions, including infection prevention and control; no registered manager was in post at the time. This explanation was written from the published report of 6 July 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 Saxlingham Hall Nursing Home
3 rated inspections over 5 years: the service has slipped, from Outstanding to Good.
- July 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Saxlingham Hall Nursing Home →
- October 2019Requires improvementdown from OutstandingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2017OutstandingSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Outstanding
- March 2020
Registered with the Care Quality Commission on 10 March 2020.
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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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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