The Sandford 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

We identified 1 breach of the legal regulations. Environmental risks had not always been fully considered. However, the provider took immediate action to mitigate risks to people. Systems to learn from accidents and incidents were not effective in identifying trends or prevent them from happening again. Risk assessments were in place to manage risks and reduce people's risk of harm however these had not always been reviewed regularly. Staff were trained in safeguarding people from abuse. Care plans provided staff with an overview of people's care needs however, these had not always been regularly reviewed. People received their medicines when they needed them. Enough trained staff were deployed to meet people’s needs, and staff received regular supervisions and training. People were protected from risks associated with the control and spread of infection.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Everyone we spoke with told us they felt safe living at the home. However, they could not always be confident that effective systems were in place to learn from incidents and mitigate risks.

The registered manager and staff told us any accidents or incidents were discussed at handovers and daily meetings. However, there were no effective systems in place to formally monitor and review any trends.

Accidents, incidents and complaints were reviewed by the registered manager every month but there were no systems in place to learn from incidents and we were unable to see actions taken to prevent the incident from happening again. For example, records only detailed the number of accidents and incidents and the name of the person involved. Records identified one person who had a high number of falls this year. Their falls risk assessment and care plan had not been reviewed since December 2023 and these records did not show that updated action had been taken to mitigate risks.

People’s needs were assessed before they moved to the home to ensure their needs and aspirations could be met. However, people’s care plans and risk assessments were not always kept up to date during their stay at the home.

Staff told us they had the information needed to ensure care was delivered in accordance with people’s needs and preferences. A member of staff said, “The care plans are good and tell you what you need to know about a person." However, staff did not always ensure people’s care plans and risk assessments were regularly reviewed.

We received mixed feedback from the health professionals about how well the service communicated with them to ensure information was transferred across services when required.

There were systems in place to ensure people’s needs, associated risks and aspirations were fully assessed before they moved to the home. However, people's care plans and risk assessments were not always regularly reviewed.

People told us they felt safe living at the home and with the staff who supported them. One person said, “I am safe here and the staff take good care of me.” Another person told us, “All the staff are lovely. They are very kind to me.”

Staff told us they had received training about how to recognise and report abuse. They knew how and when to report concerns both internally and to other organisations such as the local authority, CQC and the police. A member of staff said, “I’ve never witnessed any unkindness here, but I would definitely report it if I did.”

People looked relaxed and comfortable in their surroundings and with the staff who supported them. Staff interacted with people in a kind and respectful manner. Staff responded quickly to any requests for assistance.

There were systems in place to ensure all staff received training and regular refresher training in safeguarding adults from abuse. Safeguarding incidents were reported, recorded and investigated, however processes for analysing accidents and incidents were not always effective in identifying emerging themes or patterns.

Some people were able to understand potential risks associated with their daily lives. One person who had recently moved to the home told us staff had discussed their safety with them as they had experienced a number of falls before moving to the home. The person told us staff had shown them how to use the call bell and they had agreed with staff they would ring their call bell before leaving their bedroom to alert staff. Where people were unable to understand risks, staff knew how to keep them safe, for example by providing them with modified diets where people were at risk of choking and by ensuring people had access to mobility aids. However, care plans and risk assessments had not always been regularly reviewed and some were not reflective of people’s current needs.

Staff understood people’s needs and associated risks however the care records which guided staff were not always up to date. Staff told us they had been trained and had access to equipment needed to support people in a safe way. Catering staff told us they were made aware of any risks associated with eating and drinking and knew how to prepare modified diets.

Staff supported people to maintain their independence safely. For example, ensuring people had access to their mobility aids and access to call bells when they were alone in their bedroom. When people requested assistance, staff responded without delay.

Risks to people were assessed and measures were in place to reduce risk, however some risk assessments had not been reviewed for several months. The registered manager explained this was in the process of being addressed as they were in the process of moving from paper-based care records to a computerised care planning system.

People lived in a comfortable environment and each person had their own bedroom which they could personalise in accordance with their tastes and preferences. However, people were not always protected from environmental risks.

Staff considered environmental risks to people when assessing their needs and they understood how to minimise potential risks to people. However, they had not acted on risks we observed during our visits to the home.

We observed the door to a sluice room containing hazardous chemicals had been left open posing a potential risk to people. We discussed this with the registered manager at the time of the visit and immediate action was taken. One bedroom window above ground floor level had not been fitted with a restrictor and was able to open wide enough for a person to pass through. Other windows had been fitted with in frame restrictors which could be easily bypassed. We saw this to be the case where a bedroom window was wide open. We discussed this with the registered manager at the time who arranged for the provider’s property team to fit appropriate tamperproof window restrictors. This was addressed following our visits.

There were extensive checks on the environment and equipment used by people to ensure they remained safe. Regular servicing was carried out by external contractors on moving and handling equipment, fire alarms and detection systems and the lift. An up-to-date fire risk assessment was in place and there were contingency plans to manage unforeseen events. However, in house checks on the environment had failed to identify the issues we found with the window restrictors. We also found gaps in-house checks, such as weekly fire alarm tests. The registered manager told us this was when the maintenance person was on leave and acknowledged that suitable arrangements needed to be put in place to ensure all checks were carried out in the absence of the person responsible.

People were supported by enough appropriately trained staff to meet their needs safely. One person told us, “It’s very nice here and the staff are lovely.” Another person who preferred to remain in their bedroom said, “The staff come and talk to me. They are kind and respectful.”

Staff told us there were enough staff to meet people’s needs. Staff were positive about the training and support they received. A member of staff said, “The training is very good. You get all the training you need and can request extra training if you need it.” Another member of staff told us, “I have regular supervisions and feel really supported.”

There was a good staff presence throughout the home and people did not have to wait long for assistance. There were regular checks on people who chose to spend time in their bedroom or were being cared for in bed. Staff spent quality time with people engaging in conversation or activities. The atmosphere in the home was happy and relaxed.

The provider operated safe recruitment processes. This included undertaking appropriate checks with the Disclosure and Barring Service (DBS) and obtaining suitable references. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staffing levels were based on the needs and number of people who lived at the home and were kept under review. Staff received regular training appropriate to their role and there were regular checks on their performance and knowledge to ensure they remained skilled and competent. All new staff received a period of induction which gave them the skills and knowledge and training to meet people’s needs.

People were protected from the risks associated with the spread of infection because staff followed the provider’s procedures and best practice. People lived in a home which was clean and fresh smelling.

Staff had received training in infection, prevention and control and understood the importance of following correct procedures. Staff told us they had good supplies of disposable gloves and aprons.

All areas of the home were clean and smelt fresh. Staff attended to any spillages straight away. Staff were observed using personal protective equipment (PPE) such as gloves and aprons, appropriately. Handwashing facilities and sanitising gel were appropriately sited throughout the home.

An infection, prevention and control policy was in place which was regularly reviewed to ensure it reflected current guidance and best practice. Staff had received training in infection, prevention and control. Cleaning schedules were completed daily to ensure good hygiene standards were maintained. Designated cleaning staff were employed.

People received their medicines when they needed them from staff who were trained and competent in their role. One person said, “I take lots of tablets and I get them when I need them. They [staff] are pretty thorough on that.”

Staff told us only registered nurses were involved in administering people’s medicines. When staff administered medicines, their time was protected which reduced the risk of errors.

There were policies and procedures in place for the safe management and administration of people’s medicines and these were understood and followed by staff. Medicines were stored securely and there were systems in place to ensure people always had sufficient supplies of their medicines. There were regular stock checks and audits to ensure people received their medicines as prescribed. However, there had been no stock checks on controlled drugs since 22 June 2024. There were protocols in place for medicines prescribed on an ‘as required’ basis which helped to ensure staff followed a consistent approach and people received their medicines when needed.