Stoneacre Lodge Residential 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

Safe – this means we looked for evidence people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk people could be harmed.

The service was in breach of legal regulations in relation to people’s safe care and treatment.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety. The management team did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. There was not a learning culture in the care home. Accidents and incidents were not routinely reviewed and themes and trends were not identified. Information from accidents and incidents was not used to improve the quality of care and support or to improve the caring practice of the staff team.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. People’s care plans had not all been updated and there was inconsistency in how information was stored and collated which meant it was not always possible to ensure consistency of information when people transferred between services.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how this could be achieved. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. The provider had not always made referrals to the local authority when there were concerns about people and the safety of others. Investigations into these concerns were not carried out to identify how to mitigate risk in the future.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. There had been some improvement to how care plans were reviewed and updated on the provider’s electronic care planning system but we did not see evidence of how people, or their families, had been involved in these discussions. Management and organisation of care plans and supporting documentation was, in some cases, disorganised and ineffective. Care was not always delivered in line with people’s care plans. For example, 1 person was identified as being at risk of developing pressure sores but there was no information in their care plan about what should be done to mitigate this risk. The care plan identified the need to check the person’s skin integrity but did not specify how often these checks should be completed and recorded. Whilst improvement had been made following the previous assessment, further improvement was required.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Improvements had been made to how the care environment was reviewed and monitored to ensure it was safe but there were still areas where further improvement was required. For example, the fire door to the kitchen, marked 'no unauthorised access', was propped open, and the laundry door, which had a sign on it which indicated it should always be locked, was unlocked.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care which met people’s individual needs. Our observations found staff were not always deployed effectively. For example, we heard the call bell system sounding for long periods of time prior to members of staff responding to people. People’s needs were not always met in a timely way because there were insufficient staff on duty and who were not deployed effectively. Members of staff used the sun lounge and outside spaces for their own breaks and leisure time but did not support people to access these areas. People were not supported to access the toilet in a timely manner. We observed members of staff telling a person they would come back to them ‘in a minute’ when they requested to go to the toilet. It took 60 minutes for the person to be taken to the toilet. The person told us, “It’s not good here. Sometimes I have to wait an hour for the toilet. I am only here on respite and I don’t use my pad in the daytime when I’m at home but I have to when I’m here because [members of staff] don’t come on time.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. We carried out a tour of the home and looked at cleanliness. We found areas where practice could be improved to ensure compliance with infection prevention and control processes. For example, there was not a ‘dirty to clean’ flow in the laundry room and we noted malodours throughout the service.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Management of medicines had improved following the previous inspection and the service was no longer in breach of regulations in relation to administration of medicines. We did, however, identify the service needed to make improvements in relation to how application and removal of people's pain patches was recorded. The improvements which have already been put into place need to be sustained and embedded in to practice.