About the service: Sandrock Nursing Home is a care home providing nursing and residential care to up to 28 people. At the time of the inspection there were 23 older people living at the service some of whom were living with dementia.

People’s experience of using this service:

The registered manager was working to an action plan to make sure people’s risk assessments and care plans were person centred and accurately reflected people's needs.

People told us staff were kind and respectful and we saw caring relationships had been developed between people and staff.

The dining experience had improved. people received the support they needed to eat and drink and were given choice of where and what to eat.

People had choice and control over how they spent their time. People were supported to pursue their interests such as listening to their favourite radio station or visit the local pub.

People received their medicines when they needed them and were supported to receive support from healthcare professionals.

People felt safe in the service and with the staff that supported them. There were enough safely recruited staff on duty and staff responded to people's request for assistance.

The service was clean and fully accessible and bathrooms had been adapted. People had been able to personalise their rooms with their own furniture and personal affects.

People’s capacity to make decisions was assessed and people were supported with decision making.

Staff were knowledgeable about safeguarding procedures and how to raise any concerns they had. Referrals to the local authority safeguarding team had been made appropriately. Staff received regular training to ensure they had the skills to meet people’s needs.

Staff felt well supported by the registered manager and told us they could raise any concerns with them.

There were systems in place to assess and monitor the quality of the service.

Rating at last inspection: Requires Improvement (report published 8 September 2018)

Why we inspected: This was a planned inspection based on our inspection schedule for new services.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

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

We carried out an unannounced inspection of Sandrock Nursing Home on 26 July 2018. Sandrock Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided and both were looked at during this inspection. The home provides accommodation for up to 28 people who require nursing or personal care and at the time of this inspection, 22 people were living there.

The home had a manager who was registered with CQC. 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.

At our last inspection of the service in April 2018, we identified breaches of Regulations 9, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was rated ‘inadequate’ and placed into ‘special measures’ by CQC.

During that inspection we found that people’s care plans were not reviewed to ensure they remained appropriate to their needs and preferences. Information relating to people’s level of risk was contradictory and some people’s risk management plans were not followed. Wound care documentation was poor and unclear. People who required special diets were not always provided with the diet they needed and some people’s food and drink charts did not show that they always got enough to eat and drink. The administration of medication was unsafe. The provider had audits in place to check the quality of the service but these had not been effective.

During this inspection we found that the home had a computerised care planning system, but this did not always provide the format staff needed for keeping specific records, for example wound care records. The manager told us that they had decided to use paper records for recording wound care and we saw that these were well completed, with photographs that showed the progress of healing.

Risk assessments were completed on the computer system. Following completion of the risk assessment tool, the computer generated suggested actions. These actions were not individualised and were not used in planning the care the person needed. The manager showed us that the plans for keeping people safe were recorded as care plans and not as part of the risk assessment process. We discussed with the manager that this needed to be made clearer to avoid any confusion.

Daily charts recording personal care, repositioning and food and fluid intake were well completed by the care staff and showed that people had received the support they required in these areas. However, we observed that people did not always receive the support they needed to enjoy their meals.

We looked at the arrangements for the management of people’s medication. Two people we spoke with confirmed that they received their medicines on time. Medication was stored appropriately and at the right temperatures. We saw no evidence of stocks running low or medicines being out of stock, which had been found at the last inspection.

We saw no specific guidance for staff regarding the administration of medication prescribed to be given ‘as required’, however the nurse we spoke with knew people well and could describe under what circumstances the medication would be used. We recommend that written protocols are put in place to ensure that PRN medication is administered consistently by all of the home’s nurses.

We looked at the medication administration record (MAR) sheets and there were no missed signatures. Spot checks we carried out tallied with the records. Boxed medication was counted every night by the night staff and checked by the manager. Other daily checks had been put in place but were not always co

Sandrock Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided and both were looked at during this inspection.

The home provides accommodation for people who require nursing or personal care. The home can accommodate up to 28 people. At the time of our inspection 23 people lived at the home.

There was a registered manager in post at the time of our inspection. 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.’ The registered manager has worked at the home for many years.

At our last inspection in December 2017, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 with regards to regulation 11 (Need for consent), regulation 12 (Safe care and treatment) and regulation 17 (Good governance). The service was rated required improvement. During this visit we followed up the breaches we identified at our previous visit. We found that some of the improvements made by the provider and manager of the service with regards to Regulations 12 and 17 had not been sustained. This meant at this inspection the rating for the domains of safe and well-led were downgraded to ‘Inadequate’. The issues associated with Regulation 11 had been addressed but a new breach of Regulation 9 (Person centred care) of the Health and Social Care Act was identified with regards to the ongoing review of people’s care to ensure it remained appropriate to their needs and preferences. These issues have affected the overall rating of the service at this inspection and the service has now been rated inadequate once again for the second time in 12 months.

We looked at six care plans and found some improvements to the information relating to people’s needs and wishes had been made but other information was poor. Some of the information relating to people’s level of risk was contradictory, some of the risk management advice stated was inadequate and some people’s risk management plans were not followed. This meant that there was a risk that people’s health and welfare were not being managed properly. Clinical wound care assessment and management remained poor and unclear. This meant it was difficult to tell which people had pressure sores in place and what care they were receiving. Pressure area care to prevent the development of a pressure sore was not always provided consistently and some staff lacked adequate knowledge of what this care was.

People who required special diets were not always provided with the diet they needed and some people’s food and drink charts showed that they did not always get sufficient amounts to eat and drink. This meant people’s care was not provided in way that sufficiently mitigated risks to their health and welfare in order to maintain their well-being.

The administration of medication was unsafe. People’s medication was not always ordered in a timely manner to prevent them from running out. The balance of medication stock in the home did not match what had been administered and it was clear that some people had not received the medication they needed. There were no system in place to record the administration of prescribed creams, topical ointments and thickening medications for people who needed to have their drinks thickened so that they could swallow safely. This meant there was no evidence that these medications had been administered appropriately or in safe way. Some of the medication in the home was not accounted for on people’s medication charts yet they had been administered. People’s health and welfare are place

Sandrock Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to provide accommodation for up to 28 people who require nursing care. The inspection of this service was unannounced and took place on the 19 December 2017.

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.’ The registered manager was a long standing member of staff and had been in post for over 13 years.

At our last visit to the service in June 2017, we identified multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was rated inadequate and placed in special measures. During this visit we followed up the breaches we identified at our previous visit and found that improvements had been made. We found that some further progress was still required with regard to Regulation 11 in respect of the need to obtain consent in accordance with the Mental Capacity Act 2005 and Regulation 12 with regard to safe care and treatment and the service remained in breach of these regulations. This demonstrated that there were still aspects of the service that were not well-led which meant the service remained in breach of Regulation 17 in respect of good governance. It was clear however that the manager and staff team had worked hard in the six month timescale between inspections to address the majority of the concerns previously identified. As a result of the improvements made, the domains of safe, effective and well-led which were rated inadequate at our last inspection, received a new rating of ‘requires improvement. The ratings for the domains of caring and responsive remained the same.

We looked at the care files belonging to six people. We saw that the assessment of people’s risks had improved. The majority of people’s risk management plans contained sufficient information for staff to follow to mitigate risks in the delivery of care and people’s care plans were person centred. This meant that people’s individual needs, preferences and wishes in relation to their care were documented for staff to be aware of in the delivery of care. We identified continued concerns with the documentation of people’s wound care. This information still remained unclear which meant it was difficult to tell if people’s wounds were healing and if people were in receipt of the care they needed. Risk assessments demonstrating that some people’s bed rails were suitable for their use were not always available or regularly reviewed to ensure they continued to be the safest option to meet people’s needs. We spoke with the manager about both of these issues.

It was obvious that the manager had considered the use of the Mental Capacity Act 2005 in the planning and delivery of people’s care since the last inspection but further improvements were required. This was because some people’s capacity to consent to decisions about their care had been assessed where their capacity to consent was in question, but other people’s capacity had not. This meant there was no evidence that some people’s consent to their care had been legally obtained.

Concerns identified at the last inspection with regards to the premises, the call bell system and the recruitment of staff had all been addressed. A new call bell system was in place and operational in all parts of the home. People had access to call bells and there was an automated system in place to alert staff to check on the welfare of those

The inspection took place on 7 and 15 June 2017 and was unannounced. The service is registered to provide accommodation with nursing care for up to 28 people and 27 people were living there when we visited.

The home had a manager who was registered with the Care Quality Commission. 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.

Our last inspection of the service was on 2 August 2016 and we found breaches of Regulations 15 and 17 of the Health and Social Care Act 2008 because the provider had not ensured that the environment was properly renewed and the provider did not have effective systems in place to assess, monitor and improve the quality and safety of the service.

During this inspection we found that some improvements had been made to the décor of the home and to the home’s quality assurance processes, however we found breaches of Regulations 9, 11, 12, 13, 17, 18 and 19 of the Health and Social Care Act because: people were not kept safe; people’s capacity to consent to their care had not been assessed; safeguarding incidents had not been reported; there was inadequate information to show that staff employed were of good character; not all staff had received training; people’s care records were incomplete; and the provider’s quality assurance processes had failed to identify and address these issues.

We found that most people did not have access to a nurse call bell either in their bedroom, in toilets or in the lounge. Some people told us they would ‘shout’ if they wanted to ask for support.

When we opened a fire exit leading into the back garden this did not activate any alarm. The back garden was overgrown and contained rubbish and the gate leading to the road was unsecured. This meant that people who may not be safe to do so could leave the building without staff being aware.

Personal emergency evacuation plans, to show how people should be supported to leave the building in case of emergency, were not fit for purpose, for example they did not specify either the floor of the building or the bedroom number. A significant number of staff had no date recorded for fire safety training.

Care plans did not provide sufficient risk management advice. This led to unsafe moving and handling practices and lack of clarity regarding the use of thickeners in people’s drinks. Only six members of staff had attended practical moving and handling training in 2016 and none in 2017.

Accidents and safeguarding incidents had been reported and investigated internally but had not been reported to external bodies.

Personnel files for two new staff did not contain verified references and 17 members of staff had a criminal records disclosure that was more than ten years old. This meant that we could not be sure that all of the staff team were safe to work with vulnerable people.

In general, medication was managed safely, however two people’s eye drops had not been dated on opening and another bottle of eye drops was dated February 2017, which meant they were past their expiry time.

We found a lack of information about people’s ability to make decisions and people’s mental capacity had not been assessed as required by the Mental Capacity Act. The manager was unclear about her responsibility with regard to mental capacity assessments. Consent to care had been obtained from people’s relatives who did not have Power of Attorney to give them legal power to do this.

Some staff had completed the home’s electronic training programme, but others had very little training recorded. This meant that staff may not know how to provide support to people in a safe manner. We found a similar situation during our last two inspections of the home.

People did not

The inspection took place on 2 August 2016 and was unannounced. The service is registered to provide accommodation with nursing care for up to 28 people and 26 people were living there when we visited.

The home had a manager who was registered with the Care Quality Commission. 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.

During the inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the end of this report.

We found that the home was clean and routine maintenance tasks were carried out, however it is an old building and many areas required redecoration and refurbishment to provide a pleasant environment for people to live in.

The manager carried out some audits of the service, however these had not all been kept up to date and did not provide useful information to show how the service could improve.

During the inspection we saw that there were enough staff to support people and meet their needs. People we spoke with were very happy with the staff and with the care provided to them. The care plans we looked at gave details of people’s health and support needs and had been kept up to date. Medicines were generally stored and managed safely, however some improvements were needed.

The manager was aware of her responsibility with respect to the Mental Capacity Act and Deprivation of Liberty Safeguards.

People told us they enjoyed their meals but we considered that some people would benefit from the opportunity to have their meals at a dining table.

We considered all of the evidence we have gathered under the outcomes we had inspected. We used the information to answer the five questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Is the service safe

On the day of our inspection we found the environment to be clean and fresh.

We saw enough staff on duty to meet the needs of the people who lived at the home and were told that the manager or senior nurses were always available either working in the home or on call in case of emergencies.

People who lived in the home and their relatives told us that the service was safe and they felt safe living there.

We saw training records which identified that staff received training relevant to the needs of the people who lived in the home. The training programme did however identify that staff required up dates to ensure they were up to date with good practice.

The Care Quality Commission (CQC) monitors the operation of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) which applies to care homes. At the time of this inspection one application had been made by the home and was being implemented by the home with the support of the local authority.

We looked at the use of equipment in the home and found that in relation to the use of the bedrails and protective bumpers there were monthly reviews and daily checks of their use to keep people safe.

There were issues in relation to the safe storage of frozen food in the home.

Is the service effective?

People told us that they were happy with the care and their needs were met. It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and knew them well. One person told us. "The staff are wonderful here. I could not be happier the way they care for my relative".

Staff had received training to meet the needs of the people living at the home, however the provider may wish to note that they need to ensure the training programme is met more effectively as there are gaps for some staff.

Is the service caring?

We spent time in all areas of the home where we observed staff caring for people with dignity and respect. People living at the home appeared settled and well cared for and did not raise any issues of concern with us. One person visiting the home told us ''The staff keep me very involved as I visit daily'' another commented ''The home cares for my relative extremely well''. People told us that they were happy with their care. We spoke with staff and found that they knew the people living in the home very well.

Is the service responsive?

People's needs were assessed before they moved into the home and records confirmed people's preferences, interests and health needs were recorded. We saw that when people’s needs changed they had been referred appropriately to the relevant health professionals such as the G.P. chiropodist and dietician. A family member told us that their relatives care and support had been reviewed and altered according to their changing needs.

Is the service well led?

Staff had a good understanding of what was required of them in their role and the good standards of care that they were expected to deliver. We were told that the provider of the service and the registered manager spends a lot of time in the home. People who lived in the home told us that they are always available for a chat. We saw that the provider now had a continuous program of refurbishment and improvement to ensure that people lived in safe comfortable surroundings. Staff told us that the manager supported them to attend training.

At inspection of this service on 9 August 2013 we found the environment in which people were cared for did not support their health and welfare. It was not sufficiently clean and safe and people were not protected from the risk of infection. We issued the provider with compliance actions to address the failings. We also found that systems to monitor the quality of the service provided continued to fall short of required standards.To make sure that these failings were addressed we issued a warning notice.

Prior to re-inspection of the service we received concerning information about maintenance of equipment and lack of working call bells. We found these issues had been, or were being acted on and addressed. There was a plan in place for improvements to the premises and a considerable amount of work had been carried out since our previous inspection. Infection control issues and maintenance checks had been carried out and the provider was working towards a robust audit plan to ensure they were continually monitoring and improving themselves.

We observed people were well cared for and staff and residents interacted well. Eight people spoken with said they were happy with the service provided. Comments included "I am very well looked after", "I feel safe and the girls are respectful", "I am kept clean and well, I am comfortable and I like the staff". A relative told us "I come here every day and I would know if there was anything bad going on - I am all eyes and ears".

We went back to Sandrock Nursing Home to follow up a warning notice on records which was served following our inspection on 15 May 2013. We also followed up concerning information we had received about a lack of cleanliness and the safety and suitability of the premises and checked whether there was any negative impact on the care and welfare of the people who lived at the home.

People we spoke with and their relatives told us they were very happy with the care provided. Comments included:

"Mum is always clean. Staff have been here a long time and they know her care needs.";

"I am happy living here and I am comfortable."; and

"The girls are good, and they look after me.";

We spoke with the registered manager and reviewed the records that we had concerns about. Records had been re-written and we found that care plans were person centred and informative and clearly identified each person's care need. There was instruction to staff about how care needs should be met and where risks had been identified there were management plans in place. The manager said all the care records were being re-written in this way.

There were environmental health concerns such as kitchen windows without fly screens and food stored inappropriately alongside cleaning substances. We saw loose floor tiles, cracked bath tiles and inadequate storage facilities creating potential hazards and making the premises unsafe and unsuitable. Steps were being taken to address some concerns.

People living at Sandrock Nursing Home told us "I'm well looked after, I can't grumble", "All the girls are very respectful" and "My basic needs are met".

We observed care throughout the inspection and saw that people living at the home were spoken to respectfully and caringly by staff looking after them. We saw people were consulted about their care, received assistance when required and were given choice. We saw the activities co-ordinator carrying out a session with those who wished to join in. People were smiling, animated and busy with activities at the time of our inspection.

We found that there was a selection of foods available and were told that alternatives were available. One person said "I eat what's put in front of me - there's no choice" but four other people told us that the food was fine and they could choose alternatives if they did not like something. One person said "If I don't like what is on the menu I will ask for something else".

There were enough staff at the home and staff we spoke with told us they were happy at work and understood the needs of the people they cared for.

We reviewed compliance actions set at the last inspection and found that information about people's care needs continued to be insufficiently recorded. We also found that the provider still had ineffective processes in place to assess and manage risks and monitor the quality of the service provided. We have asked the provider to take action to resolve this.

Prior to our visit we had received concerns about the care of a person using the service and about care records held at the home.

We spoke with four people who used the service and a relative. They told us they were treated very well and with dignity and respect. People told us they were spoken to with respect; staff listened to them and acted upon their choices. They told us staff responded well and with timeliness if they called for assistance. They told us they were very happy living at this home. They said:

“I love it here, I never want to leave”, “I am very happy living here, they look after me very well”.

We observed that staff treated people well and in a caring manner. They understood people’s different behaviours and responded accordingly, adjusting their manner and how they cared for them to the person’s needs.

We found that care records contained relevant information in relation to personal details, assessment of care needs, risk assessments and care plans. We found that records identified people’s needs and how their needs were to be met. Risk assessments were in place and were individualised. However care records were not accurate nor were they stored safely.

We found that improvements had been made in respect of staff training, supervision and appraisal and in monitoring the quality of service provided. However action plans were still in progress by the manager in order to achieve compliance within timescales agreed.

We spoke to relatives of people who use the service when we visited on 24 July 2012. People we spoke to said they felt well involved with their relatives care, felt staff listened to them and would respect their wishes where possible. We were told staff were approachable and felt they would be able to contribute views and suggestions regarding care and that this would be listened to. However those we spoke to were not fully aware of a written care plan and had not been asked to give written agreement to this.

All those we spoke with told us they felt their relative and themselves were always treated well and with dignity and respect. People said “It’s very good here”, “They do everything well and treat you with respect”.

We spoke to visiting healthcare professionals who told us they visited regularly and had never any cause for concern over the welfare of people living there. They told us staff appeared to care well for these people and were always polite, respectful and helpful.

We visited the home on 19 July 2011 and spoke to people who use the service, their family members, staff and management. Those we spoke to said they felt well cared for and looked after at Sandrock Nursing Home. They commented that it was “brilliant”; they were “cared for very well”, “feels like a big family here”, “has a homely feel” and generally were “more than satisfied” with the care given.

One husband of a service user described how he and his son were able to have a look around before deciding that his wife would go and live at the home. Other family members told us that they were involved with and kept informed of everything that went on with their mother. They told us that the staff would contact and speak to them regarding things such as the service user’s nutrition. It was always acceptable for family to bring food in, the staff were always amenable and would prepare the food for the service user.

Those we spoke to felt that they were always involved in their care and treatment options and that their views and comments were always listened to. One family member told us that he had completed a service user questionnaire and felt able to comment on the service at anytime and that his views would be listened to. Others told us that they often had informal chats with staff and management and felt their views were listened to.

They told us that they felt safe in the home and felt they were well cared for.

The inspection took place on 26 November and 1 December 2014 and was unannounced on the first date. The service provided accommodation with either personal care or nursing care for up to 28 people. The home had a manager who was registered with the Care Quality Commission. 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.

There was a team of 35 staff including registered nurses, health care assistants, and ancillary staff. During our visits we saw that there were enough staff to support people and meet their needs, and people we spoke with considered there were enough staff. All staff had received training about safeguarding vulnerable people from abuse and were updating their training.

We found that the home was clean and adequately maintained, however improvements were needed to ensure that people were protected from the spread of infection.

Medicines were stored safely, however improvements were needed to arrangements for medicines prescribed to be given ‘as required’ to ensure that this was done consistently.

People we spoke with confirmed that they had choices in daily living and we observed that people could choose where they spent their time, but improvements were needed to involve people more in the planning of the care and how the staff recorded this information

People were registered with local GP practices and district nurses supported people who were not funded for nursing care. The care plans we looked at gave details of people’s health and support needs and the care plans had been kept up to date.

Improvements had been made to the kitchen and food storage areas and people were happy with the meals they received.

People’s needs were assessed before they moved into the home and referrals were made to medical professionals as needed.

The manager carried out audits of the service and a satisfaction survey had been carried out and responded to.