Archived: Sandrock Nursing Home

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. This is the first assessment for this service under a new provider. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation 15 premises and equipment and regulation 12 in relation to people’s safe care and treatment.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice and lacked robust oversight of the service. There was a clear lack of progress made to address issues with the environment and health and safety monitoring of the service. Staff understood the importance of recording accidents and incidents and did so in a timely manner.

The provider did not always work well to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. With the significant environmental issues found the provider had not considered how this impacted people and limiting possibilities to use other parts of the building such as the garden areas and the communal bathroom. Although in the care records they showed people would like a regular bath, the communal bath was not accessible despite being recently refurbished. Staff demonstrated they knew people well and understood their needs, but we found evidence people’s care plans did not contain relevant information.

The provider did not work well with people to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. We found the condition and safety of both the inside and outside of the premises posed a risk of avoidable harm to people. The provider did not operate robust procedures and processes that made sure people were protected from environmental risks. For example, the provider had not carried out health and safety checks or taken all reasonable steps to ensure the premises were safe, including addressing fire safety risks. This exposed people to the risk of harm.

The provider did not always work well with people to understand and manage risks and they did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The provider had failed to appropriately assess, monitor and manage risks to people's health and safety by neglecting the environment placing people at risk of harm as detailed throughout this assessment. We did observe people's care needs being met by the staff. Where people required assistance with walking or being transferred using equipment, staff provided this in a person-centred way. We observed people in the dining room, where people required assistance with their dietary requirements, they were being encouraged to be independent, and staff took time to speak in an attentive and caring way to the people.

The provider did not detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We found serious concerns with the safety and condition of both the inside and outside of the premises. Occupied and unoccupied bedrooms were in very poor condition. Bedrooms, communal areas and garden areas were unsafe and in a poor state of repair exposing people and others to the risk of avoidable harm. The door to the lounge, where people spent most of their day, did not have a properly fitted seal at the bottom. Instead, cardboard and tape had been used, and the door did not fully close. Fire doors, when properly fitted and maintained, prevent the spread of fire and allow more time for evacuation. The issue with the door was reported to the provider in the maintenance log on 10 January 2025 and again on 8 June 2025. The provider failed to take action, increasing the risk of serious injury or death in the event of fire. Multiple occupied and unoccupied bedroom doors did not close into the recess and had out of shape threshold seals meaning the doors did not fully close. We asked the maintenance staff who was on site what hours they worked at Sandrock Nursing Home, and they told us, “I fell into the roll.” We could not find any meaningful methods to contact the maintenance worker as they were not employed permanently by the provider. The manager, kitchen staff and a nurse told us they wrote down concerns in the maintenance book to highlight any repairs needed.

Several bedroom windows on the second and first floors did not have window restrictors, and the windows could be opened over the 100mm recommended gap and therefore people could be at risk of falling out of these windows. We observed directly outside an unoccupied bedroom a bird’s nest on the windowsill with bird faeces and feathers in the bedroom. In the rear garden, we observed multiple items on the ground including an empty glass, paint brushes, screws, roof tiles and uneven paving. Two storage units which were unlocked and contained old mattresses, cleaning products and machinery. An electrical unit in the rear garden was open and plant materials growing inside the unit. This posed a risk to people and the public as the rear garden was not secure. Unoccupied bedrooms, which the provider told us would be decorated once new admissions moved in where in poor state.

Sandrock Nursing Home does not have enough bathing or shower facilities for the premises intended purpose. The provider was registered 28 people and did not have any adapted bathrooms or shower rooms on the first or second floor. There was a bathroom and wet room on the ground floor. However, in the newly refurbished bathroom on the ground floor we observed and confirmed by staff, none of the people were able to use the bathroom due to the bath not being adapted appropriately for people. There was not an appropriate number or accessible bathing facility and only one shower room to support people’s personal care and hygiene.

The provider did not always make sure staff received effective support, supervision and development. Staff told us they did not feel comfortable with one of the directors who visited the service. Staff told us, “[Name] is very arrogant and walks around swearing” and another said, “When [Name] comes to Sandrock I feel nervous and worried.”

We requested a staff structure from the home manager, and we saw there were four directors, one being the nominated individual. Staff confirmed they had not met or spoken with the nominated individual either on or off site. Staff confirmed they had met two of the directors but were not aware of the fourth director. The provider failed to ensure staff were given clear and concise roles and responsibilities of the directors at the provider. The provider made sure there were enough qualified, skilled, and experienced staff. Appropriate training had been complete so staff could do their jobs safely. This included: Risk Assessment Awareness, Safeguarding Adults (Level 1 2) and Moving Handling.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.Although some areas on the ground floor had been updated, we noticed malodourous smells and old, worn-out furniture throughout the building. This increased the risk from a spread of infection. There were stale smells in several bedrooms despite the provider telling us they had given the service an uplift including decorating the top two floors, which included replacing old carpets and painting over old wallpaper and refurbishing the ground floor.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Although we saw staff were competent and were working hard to deliver the safe administration and management of medicines, we found the provider had failed to ensure topical creams were stored safely. For two people using the service, topical creams that should have been kept in a locked cabinet were found in unlocked bedside drawers. People were supported to take their medicines safely as prescribed by staff who had received training to do so.