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Sandbeck House Residential Home Inadequate

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 31 March 2021

About the service

Sandbeck House Residential Home is registered to provide accommodation and support for up to 38 older people and people living with dementia. There were 25 people living in the home on the first day of our inspection.

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

The provider was still failing to effectively assess and mitigate a wide range of risks to people’s safety and welfare in areas including premises and equipment; infection prevention and control; individual risk assessment and medicines. There was very little evidence of organisational learning from significant incidents. Some care practices put people at risk of harm.

The provider was still failing to effectively assess, monitor and improve the quality of the service. Following the departure of the registered manager in November 2020, the provider had not made adequate alternative arrangements to ensure the safe and effective management of the service.

There were still significant shortfalls in the care planning system and the provider was still failing to maintain full compliance with the Mental Capacity Act (2005).

Notifications about events that had happened in the service had not been submitted to the Care Quality Commission, as required in law.

Care staffing levels were generally sufficient to meet people’s needs but action was required to ensure a senior staff member trained to administer medicines was available on every night shift. The provider had failed to properly address staffing absences in the house-keeping team.

More positively, staff were generally happy in their work and spoke highly of the leadership and support provided by the manager. Both the nominated individual and the manager were open to feedback and took immediate action to address many of the issues of concern we identified on our inspection.

Staff recruitment was safe.

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 Requires Improvement (published 12 April 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found insufficient improvement had been made and the provider was still in breach of regulations.

Why we inspected

We received concerns about the safety of care provision and the effectiveness of organisational governance. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led.

We reviewed the information we held about the service. No significant issues of concern were identified in the other key questions. We therefore did not inspect them, although we did follow up the breaches of regulations found at our last inspection. Ratings from previous comprehensive inspections for the key questions of Effective, Caring and Responsive were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.


At this inspection we identified four continued breaches of regulations relating to the safety of service provision; care planning; monitoring service quality and compliance with the Mental Capacity Act (2005). We also identified a new breach of regulations regarding the notification of significant events.

In response to these breaches we have imposed additional conditions on the provider's registration, requiring the provider to take action to improve organisational governance. The action we have told the provider to take can be seen the end of this report.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate t

Inspection areas



Updated 31 March 2021

The service was not safe.

Details are in our Safe findings below.


Requires improvement

Updated 31 March 2021



Updated 31 March 2021


Requires improvement

Updated 31 March 2021



Updated 31 March 2021

The service was not well-led.

Details are in our Well-Led findings below.