Sandholme Fold

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Pre-admission assessments were carried out before people were admitted to the home to ensure they could meet the individual’s needs. These assessments were completed by the manager or deputy manager or, when the person was coming to the service from hospital, by a trusted assessor.

People’s relatives told us the admission procedure was managed well with one person describing the experience as ’very smooth’ and said their loved one was ’made to feel happy’. Other relatives told us the liaison from the home was very good and they received plenty of information.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns appropriately. Improvements were needed to make sure Deprivation of Liberty Safeguards (DoLS) were managed well.

The new manager had not received support in understanding management of DoLS and was not fully aware of who had a DoLS in place and what actions staff needed to take to make sure they were compliant with the requirements of some DoLS, known as conditions. A member of the provider’s wider management team told us they would support the manager in their learning in this area. Staff knew who had a DoLS in place but were unsure about where they should make records to demonstrate compliance with conditions.

Systems and processes were in place to make sure any concerns about people’s safety were reported and managed in a timely way. Managers and team leaders knew how to make safeguarding referrals to the local authority and care staff knew to report any concerns they might have. Staff had received appropriate training in safeguarding and information relating to safeguarding was available on noticeboards.

All of the people we spoke with felt they, or their relatives were safe. People said they trusted staff and could speak to them if they had any issues.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and supportive.

Key risks relating to areas such as falls, nutrition and skin integrity had been reviewed and well managed for some people, but this was not consistent. For example, care plans, risk assessments and updates from health professionals were all in place for one person whose nutritional needs had been assessed as being a cause for concern. However, the care plan for another person at risk of weight loss contained contradictory information and staff did not always follow the detail of the care plan. Nutritional intake records for this person were not consistently completed.

A care plan for 1 person at risk of pressure damage said they needed to sit on a pressure cushion. This was not in place and when we asked staff about it, they were unsure of how the cushion should be used.

We saw, on a number of occasions, staff reminded people to use their walking aids, as per their care plans, to promote safe mobilisation.

A relative told us their family member had expressed some serious health concerns but despite speaking with a member of the management team about this, did not think anything had been documented. We checked this person’s care records and saw neither a risk assessment or care plan had been developed in relation to this. However, we were assured that referrals had been made to appropriate health care professionals.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Systems were in place to make sure regular safety and maintenance checks were completed and systems for fire safety were in place. However, some equipment was not always systematically checked, such as lifting slings and mattresses. We also noted people did not have individually assigned slings for use when hoisting to ensure safe and effective moving and handling.

The provider assured us they were addressing these issues and had arranged for a complete review of equipment in the home.

Refurbishment of bedrooms and communal areas was ongoing, and maintenance staff used their initiative to identify and prioritise this work.

The provider did not always make sure there were enough qualified, skilled and experienced staff available to meet people’s needs. They did not always make sure staff received effective support, supervision and development. Staff did not always work together well to provide safe care that met people’s individual needs.

Staff were recruited safely but we saw little evidence of effective induction processes. There was some misunderstanding between staff about whose responsibility it was to ensure inductions were completed and there was no oversight of this. The induction documentation for the newly appointed manager and deputy was incomplete and indicated that many of the aspects of the induction had been signed as completed on the same day. Additionally, the dates recorded for the start of the induction for the manager were January and February when they did not commence in post until May 2025. No interview notes were available for the appointments of manager or deputy manager to show how they had been assessed for their roles.

Staff had received training, but the training matrix indicated some staff had not received refresher training for several years in areas such as medicines management and dementia care. There was also limited evidence of staff having received first aid training, with only 4 care assistants having completed basic life support, and 1 team leader having done first aid. The manager confirmed there was no system currently in place to routinely check staff competencies for areas of practice other than medicines.

On the first day of the inspection, we noticed staff were not always confident with moving and handling manoeuvres. We discussed this with the manager who took action to ensure all staff had up to date training.

Staff supervision was not consistently completed and when it was, there was little evidence of this being supportive. For example, supervision and performance review notes were recorded identically for different staff and based on the same agenda of reminding staff about expected practice. Staff told us they viewed supervision as more of a ‘telling off’ and we saw evidence to support this. The provider showed us how this would be addressed with a new supervision format moving forward.

Staffing levels were adequate to meet people’s basic needs, but deployment of staff was not always effective. Care staff told us team leaders did not get involved in providing direct care to people and this could make things difficult at times. This was evident at mealtimes and also at times when buzzers were sounding continuously. Care staff did not always have sufficient time to spend engaging with people in activities.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. The provider worked with appropriate agencies when the risk of infection was identified.

Staff understood how to minimise the risk of infection and Infection prevention, and control (IPC) precautions were in place. Staff had regular access to personal protective equipment (PPE) and there were appropriate handwashing facilities. The home had recently experienced a significant sickness outbreak which had affected most people living in the home. The provider had responded with appropriate IPC measures including deep cleaning although staff told us a lack of vacuum cleaning equipmentmeant safe practice was not always followed. We also found there had been no robust regime in place prior to the inspection to ensure mattresses were thoroughly checked and cleaned. Most areas of the home were visibly clean and free from malodours, although on the first day of inspection 2 people's bedrooms had strong malodours and there was dirty catheter equipment in 1 person's room. We also noted several people had very dirty fingernails which indicated they were not always supported with good levels of hand hygiene. The provider responded to address these concerns and took action to make improvements.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People who were prescribed ‘as and when needed’ (PRN) medicines did not always have in-depth protocols in place to ensure staff would know how to give these appropriately. We could not be assured creams were being applied as prescribed as some medicated creams were not documented on the medication administration records (MARs).

We could not be assured staff managed medicines to be taken at a specific time well. We saw 2 examples of people’s medicines being left with the person which meant staff were not assured the dose had been taken. One person’s relative told us their loved one was given their medicines but not supervised to take them. Managers acknowledged this should not be happening and said they would take action to speak to staff about this.

Improvements were needed to make sure medicines delivered through a patch applied to the skin were applied to different sites on the person’s body to avoid skin irritation.

Medicines were stored safely.