Stoneleigh House

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 that 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 that people could be harmed.

The service was in breach of legal regulation in relation to the safe management of medicines, safety of the premises and equipment, staff training, adherence to the Mental Capacity Act and record keeping relating to modified diets, nutrition and hydration.

This service scored 47 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider recorded accidents and incidents on documents named ‘harm logs’, which they are required to send to the local authority. These forms detailed what had happened, who was involved and actions taken. The provider also used a separate document; a falls safety cross, to record how many falls had occurred each day within the home and who had fallen. However, we saw no other systems in place to capture accidents, incidents or falls and evidence what outcomes had been achieved from any actions taken, or what lessons had been learned, which would inform future practice. The provider did not complete any analysis of accidents or falls, to look for patterns and trends and try to identify how the risk of reoccurrence could be reduced. We asked the registered manager if they could provide evidence of any learning from accidents and incidents and they told us none was available.

Complaints were stored in a dedicated file. However, no log was in place to catalogue complaints received and detail actions taken and outcomes. We noted a complaint had been submitted in June 2025, and whist the complaint itself was on file, there was no evidence this had been looked into, a response had not been sent to the complainant in line with company policy or duty of candour followed. The registered manager confirmed the complaint had yet to be dealt with.

The provider’s complaints policy contained no reference to the Local Government and Social Care Ombudsman (LGSCO). The LGSCO look into complaints about adult social care providers, should people not be happy with how the care home / provider has dealt with their complaint. Complaints policies should signpost people to the LGSCO, as the next step in the complaints process. Stoneleigh’s complaints policy advised people to contact either safeguarding or CQC, if not happy with how their complaint had been handed, neither of which is the appropriate route.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

We received feedback from a visiting healthcare professional, who spoke positively about the care home and their working relationship with the staff. The told us, “I have been attached to this home for 7 years now. The home have a weekly ward round, with access to me, a pharmacist, occupational therapist and general practitioner as required. Communication is quite good. Staff communicate effectively, which means I don’t have to tell multiple staff the same thing. Any tasks which are set for them [staff] are done. Any follow up visits or appointments are actioned and put in the diary. I find the staff easy to work with, we have a good working relationship.”

Each person had an information pack in place, often referred to as a ‘hospital passport’ which included care plans, risk assessments and medical information, to help ensure continuity of care when people were admitted to hospital.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

Safeguarding concerns were reported to the local authority via the same ‘harm logs’ as were used to report accidents and incidents. The provider had no other dedicated system in place for storing and logging safeguarding concerns. We viewed the home’s safeguarding file, however, information contained within this was 2 years old, with no recent records present. The home’s complaints and compliments file contained a safeguarding section, however, this also contained records dating back to 2023 and nothing since. As a result, we saw no evidence of outcomes from any actions taken or reference to lessons learned, after safeguarding issues had been reviewed.

People’s care files contained consent forms, which had been signed by people deemed to have capacity. Where people lacked capacity to consent, and did not have someone legally allowed to consent on their behalf, there was no evidence the best interest process had been followed, as required under the Mental Capacity Act. Where people were subject to any restrictions, for example, being unable to leave the care home unsupported, the provider had submitted the necessary applications to the local authority to ensure this was lawful. This process is known as Deprivation of Liberty Safeguards (DoLS). The provider used a tracker to monitor applications and whether these had been granted. However, we found the tracker was not accurate, as it contained the names of some people who no longer lived at the home, whilst some others were listed as residing in a different room number than they currently did. As such, we could not be assured all DoLS applications had been tracked appropriately.

People told us they felt safe living at the home. Comments included, “I feel comfortable and happy living here” and “I feel safe here because of the environment, the residents and thestaff, all of which are very good.” A relative stated, “Mum is safe and happy on the whole.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments within people’s care files lacked detail and as a result, provided limited assurance risks had been comprehensively assessed and mitigated. For example, our reviews of records showed one person was often aggressive towards staff and other people. The management plan within their care file, merely stated to ring family and see if they can calm the person down. There was nothing to indicate what staff should do, if this was not successful.

Another person’s risk assessment referenced the importance of them being sat on a pressure cushion, to reduce the risk of pressure sores. However, there was no reference to the use of a pressure cushion or risk of skin breakdown in their skin integrity care plan or any other care plan. As such, there was no guidance for staff on how to manage this risk effectively.

Where people required the use of equipment, for example a wheelchair, there was not always a risk assessment in place, nor guidance on how to use the equipment safely, such as ensuring the lap belt was fastened and person’s feet were on the footplates.

Where people required a modified diet, information within care plans and risk assessments was misleading and/or lacking in detail. Where people had been assessed by a Speech and Language Therapist (SaLT), the most up to date correspondence was not always present within the person’s care file. As a result, it was not always clear what level of modified diet people required. Food logs were used to record people’s intake. However, due to how these had been written, it was not always clear food had been provided in line with people’s dietary needs. For example, guidance for people requiring a level 5 minced and moist diet, states foods to avoid include, dry or hard foods, foods with skins or outer shells, crispy or crunchy food and sticky or gluey foods. However, food logs for a person requiring a level 5 diet indicated they had eaten peas (which have a skin), battered fish (which is crunchy / crispy), cake (which is dry unless served with custard) and bread, which can only be given if agreed by SaLT or made following specific modified dietary guidelines (shop bought bread is not allowed).

The provider had completed a range of environmental and staff related risk assessments which had been reviewed annually. These included lone working, risk of pregnancy and care provision, legionella and infection, prevention and control.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Where people are at risk or accessing and falling from windows or balconies at a height likely to cause harm, e.g. above ground floor level, Health and Safety Executive (HSE) guidance states suitable precautions must be taken. Windows that are large enough to allow people to fall out should be restrained sufficiently to prevent such falls. The opening of the window should be restricted to 100mm or less and window restrictors should require a special tool or key in order to be opened. We identified a number of windows did not meet this guidance. We raised this with the provider, who agreed to install the correct restrictors to all relevant windows. This work was completed following our site visits.

We also identified freestanding wardrobes in people’s rooms were not secured to the wall. This increased the risk of the wardrobe being pulled over and causing harm to people. Again, this was raised with the provider, who agreed to take action to secure all freestanding wardrobes. This work was completed following our site visits.

The home’s fire risk assessment, completed by an external company in 2023 had not identified any major shortfalls, nor made reference to any concerns with fire doors. However, numerous fire doors we checked did not close fully in the frame when the door release mechanism was triggered. We also noted large gaps at the top and bottom of some fire doors. The home used the horizontal evacuation process, which involves moving people into an adjoining fire compartment on the same level, from which they can later evacuate to a place of safety. In order for this to be successful, each fire compartment needs to be fully sealed. The issues we noted with fire doors meant compartments were not fully sealed, which would allow smoke and fumes to spread more quickly than they should. We recommended the provider commissioned an up to date fire risk assessment, and complete any remedial works as a matter of urgency.

We found the home to have a lack of storage, which resulted in the dining room being used to store wheelchairs and some other equipment. This looked unsightly and also meant a large section could not be used by people.

We noted the hinges on most doors, especially those on corridors, required lubrication as they squeaked loudly when the door was opened. We also noted a number of floorboards were also noisy when walked upon. Both of these would likely be disturbing for people resting or sleeping in their rooms.

Overall, safety checks of equipment had been completed with certification in place, to confirm thy were safe to use. However, we identified issues with completion of water safety checks, to minimise the risk of legionella. The flushing of infrequently used outlets, cleaning of shower heads and completion of water temperature checks were not carried out frequently enough. Health and Safety Executive guidance states hot water should be stored at 60°Celsius, and cold water systems should be below 20°Celsius. We found there were no records of what temperature hot water was stored at in the water tanks, so we could not be assured it had been stored at the necessary temperature. We also noted some cold water outlets had been in excess of 20°Celsius when checked. Records contained no information on what had been done to address this.

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 that met people’s individual needs.

The provider documented staff training on a matrix. From reviewing this, we identified a number of issues. In July 2022, the UK government mandated that all CQC-registered health and social care providers ensure their staff receive training on learning disabilities and autism, tailored to their roles. This new legal requirement was introduced by the Health and Care Act 2022. The provider’s matrix contained no reference to such training being offered or completed.

There was no evidence training was being provided in the Mental Capacity Act, Deprivation of Liberty Safeguards, end of life care or first aid. There was also no evidence training was being provided to ensure staff had the skills and knowledge to meet the specific needs of people living at the home, for example training in continence care, nutrition and hydration, modified diets and pressure care.

Some staff had no training dates recorded on the matrix, with the words ‘mat leave’ recorded under each session. As such we were unable to confirm these staff had completed training before going on maternity leave. The matrix also indicated one senior carer had completed no training aside from medication.

We also had concerns about the validity of training dates. We noted every staff member was recorded as having completed manual handling, fire safety, basic life support and safeguarding on 3 June 2025. Every staff member was listed as having completed health and safety, infection control and dementia training on 6 June 2025. As a large number of these staff were on shift on 3 and 6 June, it was not clear how they had managed to provide care and complete multiple training courses.

The provider’s supervision policy did not specify how frequently meetings should take place. From records viewed, we noted meetings tended to be held every 3 months. Staff confirmed meetings took place and were happy with both the frequency and format of the meetings.

Overall, people, relatives and staff felt there were enough staff deployed to keep people safe and meet their needs in a reasonable amount of time. Comments included, “I think there are enough staff, and all are helpful and nice” and “There are enough staff around to manage things. They don't always answer the call bell quickly, when they don't, I bang on the floor.”

The provider used a system for determining how many staff were needed, often referred to as a dependency tool. This calculates how many care hours per day are required and how many staff are needed to meet these. It was not clear how the provider had arrived at the number of staffing hours provided per day, as these did not tally with the rota. For example, the tool stated staffing hours during the day equalled 28. However, depending on whether the senior carer was included in the staffing hours available, there were either 3 or 4 care staff on shift working 8 hours each which equalled either 24 or 32 hours. We recommended the registered manager review the dependency tool.

We found staff were recruited safely, with all necessary pre-employment checks completed and documented.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Overall, the home was clean, with effective infection control processes in place. Toilets and bathrooms contained hand hygiene guidance, paper towels and liquid soap. Personal protective equipment (PPE) stations were located on corridors, which were well stocked. This ensured staff had easy access to what they needed. Evidence was provided to show mattress checks and hand hygiene audits had been completed.

The provider kept an outbreak management file. From reviewing this, we noted any outbreaks had been managed in line with guidance, with the necessary professionals notified and involved as necessary, such as the Local Authorities Health Protection team.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medicines were not managed safely. Nine people missed doses of some of their prescribed medicines for varying amounts of time because there was no stock in the home. Two people missed doses of their prescribed laxatives, one person for 2 weeks and the other person for 3 weeks which placed them at risk of becoming constipated. Another person was unable to have their pain relief for 18 days because it was out of stock and another person missed having their antidepressant because it was not in stock.

When people were prescribed medicines to be taken ‘when required’ or with a choice of dose, there were no protocols to guide staff to ensure they were administered safely and consistently.

The records about the stock of medicines in the home were not accurate and could not always show that medicines could be accounted for, or that medicines including creams, had always been administered safely as prescribed. The records about the application of creams were not accurate because they were not made by the staff who were applying the creams.

Waste medicines were not stored safely in line with current guidelines.

We found no evidence that people were harmed at the time of the assessment because the harm is not always immediate. However, people were placed at increased risk of harm because medicines were not always managed safely.