Archived: Sandrock Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this service under new provider. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation 17 good governance.

This service scored 29 (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 shared vision, strategy and culture based on transparency, equality and human rights, safety and diversity and inclusion. The provider did not always understand the challenges and the needs and risks of people they supported. We found the provider was not aways open and transparent during the assessment. After we visited Sandrock Nursing Home on day 1 we spoke with the nominated individual and two of the directors to share our concerns. The nominated individual and directors found it difficult to recognise the issues we highlighted and showed a lack of understanding in relation to the management of risk and regulatory requirements. However following this meeting, the nominated individual was responsive to our concerns.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. There were no effective audits in place to ensure the home operated safely. Inconsistencies in the management meant the oversight of the home had not been robust, quality assurance mechanisms had not been implemented with integrity, openness, and honesty. Staff support and wellbeing had not been consistently implemented, and the provider had failed to ensure oversight. The provider did engage with inspectors during the assessment; however, one director who had prominent role in the running of the service was abusive and unwilling to accept the findings outlined in this assessment.

People did not feel they could speak up and their voice would be heard. The culture of the service did not always actively support freedom to speak up and to take action to drive service improvements. Some staff told us they felt management within the service were approachable. However, staff told us the provider and in particular the directors were not supportive and unapproachable. Staff said they did not feel there was any point speaking up as nothing would change or they would be listened to.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff described not being supported by the provider and this had an impact on their ability to work. One staff member told us they had to get a second job elsewhere due to the uncertainty and lack of communication about the future of Sandrock Nursing Home. We could not find any evidence the provider conducted regular equality and diversity focused supervisions with staff. However, staff had completed equality training.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider lacked any meaningful oversight of the service. The provider was not proactive in making positive changes. They failed to take responsibility for assessing, monitoring and improving the quality of the service and for mitigating risks to people and visitors in the building. Although the provider had shared improvement plans for the refurbishment of Sandrock Nursing Home, the plans had not been delivered to a sufficient standard. The provider did not ensure the home was safe and compliant with essential health and safety checks and fire regulations. The provider failed to maintain appropriate records to evidence compliance with health, safety and fire requirements. This exposed people to the risk of harm because the provider had not assessed and taken all reasonable steps to ensure the premises were safe.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Although the provider had shared an environmental improvement plan during this assessment, we found no evidence a health and safety risk assessment for the planned building work had been completed. This included the impact on people using the service and how their health conditions such as dementia would be impacted. One of the directors said they wanted Sandrock Nursing Home to be a, “Bijou dementia care home.” There was no evidence advice had been sought from dementia specialists on how to mitigate risk and manage the building work whilst supporting people living with dementia.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. As highlighted in this assessment the provider had not always picked up on the concerns highlighted throughout this report and did not have effective governance processes to ensure learning and improvement. The provider failed to identify and manage risks to people with the environment and fire safety within the service.