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Sandbeck House Residential Home Inadequate

The provider of this service changed - see old profile


Inspection carried out on 9 December 2020

During an inspection looking at part of the service

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 carried out on 21 March 2019

During a routine inspection

About the service: Sandbeck House Residential Home is registered to provide personal care to 38 older people, including people living with dementia. The service was supporting 36 people at the time of our inspection.

People’s experience of using this service: People did not always receive a service that provided them with safe, effective and high-quality care. Care plans lacked important information, were not always kept up to date when changes occurred and had limited direction for staff in how to deliver care in a person-centred way.

Individual and environmental risks to people had not always been identified and mitigated. Medicine records were not clear and some people had not received their medicines as prescribed. Safe recruitment processes had not always been followed. We have made a recommendation about safe recruitment processes.

Staff understood people needed to consent to their care, but restrictions had been applied to some people without their recorded consent. Where people did not have the capacity to make decisions, the documentation did not always support compliance with The Mental Capacity Act 2005 (MCA).

Systems of governance and oversight were not sufficiently robust to identify the issues we found and to drive consistent improvements. The provider and registered manager were responsive to the concerns we found during the inspection and began to implement improvements immediately.

Staff turnover had been high and the provider had met with staff to improve the management culture and staff retention. Staff told us morale was improving. Staffing levels had been calculated in line with people’s needs. Staff had access to a range of training to support them to be effective in their job role.

People were clearly at the heart of the service. Staff treated them with dignity and respect and their independence was promoted. Staff spent time getting to know people and become familiar with their likes, dislikes and preferences. A new activity coordinator had been employed and people had more opportunities to participate in a range of activities and receive social stimulation.

The views of people and their relatives were sought during care reviews, resident meetings and surveys. People felt listened to. There was a complaints procedure displayed in the service and people felt able to raise concerns and complaints.

For more details, please see the full report which is on the CQC website at

Rating at last inspection: At the last inspection the service was rated Good (report published 7 September 2016).

Why we inspected: This was a planned inspection to check this service remained Good. The service had declined to Requires Improvement; this was the first time the service had been rated Requires Improvement and we will meet with the provider to discuss their action plan.

Enforcement/Improvement action: Please see the 'actions we have told the provider to take' section towards the end of the report.

Follow up: We will continue to monitor this service and inspect in line with our re-inspection schedule or sooner if we receive information of concern.

Inspection carried out on 21 June 2016

During a routine inspection

We inspected Sandbeck House on 21 June 2016. This was an unannounced inspection. The service provides care and support for up to 38 people. When we undertook our inspection there were 34 people living at the home.

People living at the home were of mixed ages. Some people required more assistance either because of physical illnesses or because they were experiencing difficulties coping with everyday tasks, with some having loss of memory.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves. At the time of our inspection there was no one subject to such an authorisation.

We found that there were sufficient staff to meet the needs of people using the service. The provider had taken into consideration the complex needs of each person to ensure their needs could be met through a 24 hour period.

We found that people’s health care needs were assessed, and care planned and delivered in a consistent way through the use of a care plan. People were involved in the planning of their care and had agreed to the care provided. The information and guidance provided to staff in the care plans was clear. Risks associated with people’s care needs were assessed and plans put in place to minimise risk in order to keep people safe.

People were treated with kindness and respect.The staff in the home took time to speak with the people they were supporting. We saw many positive interactions and people enjoyed talking to the staff in the home. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives. People were supported to maintain their independence and control over their lives.

Staff had taken care in finding out what people wanted from their lives and had supported them in their choices. They had used family and friends as guides to obtain information.

People had a choice of meals, snacks and drinks. Meals could be taken in a dining room, sitting rooms or people’s own bedrooms. Staff encouraged people to eat their meals and gave assistance to those that required it.

The provider used safe systems when new staff were recruited. All new staff completed training before working in the home. The staff were aware of their responsibilities to protect people from harm or abuse. They knew the action to take if they were concerned about the welfare of an individual.

People had been consulted about the development of the home and quality checks had been completed to ensure services met people’s requirements.