CQC report explained · a nursing home
What the CQC found at Saxondale Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2022
Inspected but not rated; inspectors found strong infection control, but checks on some visiting professionals were not always complete.
This was an unannounced, targeted inspection on 08 February 2022. Inspectors looked at infection prevention and control, visiting arrangements and staffing pressures linked to COVID-19.
Inspectors found the home was clean, well ventilated and using PPE properly. Staff had infection control and COVID-19 training. People and staff were supported with regular testing, and visits had reopened with testing and PPE requirements.
The home was not given a quality rating. Inspectors found that some visiting professionals had not been asked for evidence of a negative test or their vaccination status. The manager took immediate action after this was discussed.
Clean environment
Inspectors found the home clean, well ventilated and free from unpleasant smells. Cleaning schedules covered frequently touched areas.
“The home was clean and well ventilated. Staff wore personal protective equipment (PPE) appropriately.” from the report
Infection control
Inspectors were assured that the home was using PPE safely, supporting testing and managing infection outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Visiting arrangements
Visits had reopened after the COVID-19 outbreak, with visitors asked to test and use appropriate PPE.
“The provider was facilitating visits for people living in the home in accordance with the current guidance.” from the report
Checks on visiting professionals
needs fixingThe home was not always checking that visiting professionals met the relevant COVID-19 requirements. Some were not asked for evidence of a negative test or vaccination status, although the manager acted immediately when this was raised.
“The service was not always meeting the requirement to ensure non-exempt staff and visiting professionals were vaccinated against COVID-19 in accordance with the current government guidance.” from the report
- 01How do you now check the vaccination status or exemption of visiting professionals?
- 02Do all visiting professionals provide evidence of a negative lateral flow test before entering?
- 03What infection control measures are currently required for visitors?
- 04How are staffing pressures linked to COVID-19 affecting care at the home?
- 05When was the home last given full ratings for caring, effective, responsive and well-led care?
This was an unannounced targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated. This explanation was written from the published report of 19 February 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, November 2021
Requires Improvement; inspectors found people were generally safe and well cared for, but records, staffing oversight and management systems were not reliable enough.
This was an unannounced focused inspection. Inspectors visited on 25 October 2021 and spoke by telephone with relatives and professionals on 3 November 2021. They reviewed care, medicines, staffing and management records, and observed daily life.
The home was rated Requires Improvement overall, and for Safe and Well-led. Inspectors found no evidence that people had been harmed, and relatives spoke positively about the care. However, care reviews and weight records were incomplete, staffing calculations were not always based on up-to-date information, and parts of the building needed repair.
A new manager had started in August 2021 and had made visible improvements, including restarting audits and reviewing care files. Further work was still needed. The inspection covered Safe and Well-led only, so the other question ratings carried over from the previous comprehensive inspection.
Positive care feedback
Relatives gave consistently positive feedback about the care. Inspectors also found that permanent staff knew people well and understood how to promote their safety.
“The feedback we received about people's care was consistently positive.” from the report
Improving management
The new manager had restarted a broad audit programme and was updating care files. Inspectors saw evidence that improvements were being made.
“Most issues found at inspection had already been identified on the provider's action plan and we saw evidence of ongoing improvements being made at the service.” from the report
Medicines and infection control
Inspectors observed good medicines practice and were assured that infection control arrangements, PPE and testing systems were in place.
“We observed staff wearing and changing PPE at regular intervals.” from the report
Incomplete care records
seriousRisk assessments and weight monitoring records were missing reviews or entries. Inspectors said this placed people at increased risk, although they found no evidence that anyone had been harmed.
“We found no evidence that people had been harmed however, the provider had failed to maintain an accurate and complete record in respect of each person who used the service.” from the report
Staffing assurance
needs fixingStaff reported that numbers could be too low, especially when agency staff were working. The staffing tool used assessments that had not always been reviewed recently.
“Without exception, staff expressed concerns about staffing numbers in the home.” from the report
Building maintenance
needs fixingParts of the home showed wear and tear, two bathrooms were out of order, and new kitchen equipment had not yet been fitted. A fire exit was blocked but was cleared during the inspection.
“Although we identified no significant safety concerns in the building, aspects of the environment were poorly maintained or showing signs of wear and tear.” from the report
Weak provider oversight
seriousGovernance systems had not prevented problems from developing. The provider had also failed to notify CQC about several incidents in the previous 12 months.
“We had general concerns about the effectiveness of the provider's governance systems as some issues, such as the environment or record keeping, had developed over time and therefore should have been acted on sooner.” from the report
- 01Have all residents' care files and risk assessments now been reviewed, including pressure damage and nutrition risks?
- 02How do you now calculate minimum staffing levels, and are those calculations based on current assessments of residents' needs?
- 03What repairs have been completed to the bathrooms, kitchen equipment and other worn parts of the building?
- 04How are incidents now reviewed and recorded, and how do you make sure required notifications are sent to CQC?
- 05What progress has been made against the improvement plan requested after this inspection?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 27 November 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 Saxondale Nursing Home
6 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2021Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- May 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- July 2015Requires improvementstayed Requires improvementEffective: Requires improvement
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- February 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 29 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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