Sandringham Care Home

Updated 19 May 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.

Inspection team

The inspection was carried out by 2 inspectors, a pharmacist specialist and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Sandringham Care Home 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. Sandringham Care Home is a care home with 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.

Inspection activity started on 16 March 2023 and ended on 14 April 2023. We visited the service on 16 and 23 March 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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 used all this information to plan our inspection.

During the inspection

We spoke with 3 people who used the service and 9 relatives about their experience of the care provided. We spoke with 11 members of staff including the registered manager, the regional manager, the deputy manager, 3 nurses, 3 care workers, the administrator and a kitchen assistant.

We received written feedback from a further 17 members of staff including nurses, care workers and activities co-ordinators. We received additional feedback from 1 professional who worked closely with the service.

We reviewed a range of records. This included 12 people’s care records and multiple medication records. We looked at 4 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed. We looked at training data and quality assurance records.

Updated 19 May 2023

About the service

Sandringham Care Home is a residential care home providing personal and nursing care to up to 92 people. At the time of our inspection there were 88 people using the service. The service supports a range of people including older people and people living with a dementia. People are supported in a specially adapted building across 3 floors.

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

Medicines were managed safely, and people received their medicines as prescribed. Some medicine records and processes were not always robust, and we have made a recommendation about this. People were kept safe and protected from the risk of abuse. Risks to people were assessed, monitored and managed. Staff were knowledgeable about people’s needs. The environment was safe, and health and safety checks were up to date. The service was clean, and staff had access to appropriate PPE. There were enough staff to safely support people and staff were recruited safely.

The service was well-led and there was a positive and person-centred culture. There were clear governance and quality assurance systems in place. Regular audits were carried out and the registered manager and provider understood their regulatory requirements. Some medicine issues had not been identified within the audits, but the registered manager responded immediately to our feedback. People and their relatives were regularly involved, and their feedback sought. The management team was approachable. The registered manager was pro-active and committed to working with other professionals and developing positive and innovative ways of working.

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

Rating at last inspection

The last rating for this service was good (published 13 March 2020).

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk. We also received concerns around the management of falls and the general standard of care provided. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

During the inspection we found no evidence people were at risk of harm from these concerns.

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.

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

Recommendations

We have made a recommendation around the record keeping for medicines and ensuring medicines systems and processes are fully robust.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.