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Saltmarsh House Residential Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 8 October 2019

About the service

Saltmarsh House Residential Care Home is a small residential care home that can provide accommodation and personal care to up to 12 people aged 65 and over in one adapted building. At the time of the inspection eight people were living at the home. People living at the home had a range of needs including some people living with dementia. People had their own bedrooms and some rooms offered an en-suit facility. People could access a range of communal spaces including a lounge, conservatory, dining room and the front and back garden area’s offered patio seating. The provider was registered as an individual (sole trader) with direct responsibility for the carrying on of the regulated activity at the location. As a consequence they did not need to have a registered manager.

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

People’s medicines were not always managed safely, and staff did not always follow best practice guidance. People’s risk management plans did not always provide accurate, person-centred information for staff to follow. The home was visibly clean and tidy, however we found infection control measures were not always robust to prevent the potential spread of infection. There were clear safeguarding procedures in place to protect people from the risk of harm. People and their relatives told us they received safe care.

Systems in place to review the quality of care and ensure records were complete and accurate were not always effective. Audits completed by the provider did not identify the issues highlighted in this inspection report. There was a clear management structure in place, and people and relatives we spoke with told us they had good relationships with the provider and staff.

Most 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 mostly supported this practice. However, systems in place did not always ensure consistently good outcomes for people were achieved when their needs changed. People spoke positively of the meals on offer and had access to appropriate levels of support from staff that knew them well.

People and their relatives told us they received kind and compassionate care. People told us staff treated them with dignity and respect and encouraged people to maintain their independence where possible.

People’s likes, and dislikes were reflected in their care plans and we saw care was delivered in line with people’s preferences. People had opportunities to engage in activities in the home on a regular basis.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was good (published 4 February 2017).

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches of regulation on this inspection. This related to safe care and treatment, as we found people’s medicines were not always managed safely or in line with best practice guidance. We found the provider did not operate effective systems or processes to ensure all people’s records were clear, contemporaneous and accurate. The systems and processes operated to assess, monitor and improve the quality and safety of the service people received were not effective.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 8 October 2019

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 8 October 2019

The service was not always effective.

Details are in our effective findings below.



Updated 8 October 2019

The service was caring.

Details are in our caring findings below.



Updated 8 October 2019

The service was responsive.

Details are in our responsive findings below.


Requires improvement

Updated 8 October 2019

The service was not always well-led.

Details are in our well-Led findings below.