Archived: Sandmartins

Updated 1 March 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by one inspector.

Service and service type

Sandmartins is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Sandmartins is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We looked at notifications we received from the provider since the last inspection. We reviewed a plan of actions the provider sent us following the last inspection.

We used all this information to plan our inspection.

During the inspection

We spoke with 4 people about their experience of the service. We spoke with the registered manager, the provider’s area manager, crisis manager and a member of care staff.

We reviewed a range of records including one care plan and multiple medication records. We looked at two staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 1 March 2023

About the service

Sandmartins is a residential care home providing accommodation and personal care to up to 40 people with a range of health care needs, including dementia, in one adapted building. At the time of our inspection there were 20 people using the service.

People’s experience of using this service and what we found

Following the last inspection, improvements had been made in a number of areas, such as the way people’s support needs were recorded in their care plans. Further actions were needed to ensure people received a consistent standard of care.

People told us they felt safe living at Sandmartins. Their risks had been identified and assessed; staff knew people well and how to support them. Staffing levels were sufficient to ensure people’s needs were met promptly and appropriately. Medicines were managed safely.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

A range of audits had been implemented to measure and monitor the service. The provider had drawn up an action plan to show what improvements had been made and what areas still required attention. People told us about their experiences of the home and were happy living there; they felt cared for by staff.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 4 November 2022) and there were breaches of regulation. At this inspection we found improvements had been made in the recruitment of staff, and in the management of medicines. Further work was required to sustain and embed the improvements made. At this inspection we found the provider remained in breach of one regulation.

Why we inspected

We undertook this focused inspection to check whether the Warning Notices we previously served in relation to Regulation 12 and Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this focused inspection and remains requires improvement.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements.

You can see what action we have asked the provider to take at the end of this full report.

This report only covers our findings in relation to the Key Questions Safe and Well Led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained the same. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sandmartins on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified a breach in relation to records of staff competency to administer medicines, the auditing of medicines and the management of care plans at this inspection. We have made a recommendation about the management of some medicines.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.