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 provider was in breach of legal regulation in relation to the way people’s medicines were managed safely.

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Staff reported and documented all accidents, incidents and complaints and these were investigated by the registered manager. Staff team meetings and supervision meetings were used to provide feedback to staff and help promote learning from such events.

However, lessons had not been learnt or sustained following our previous enforcement action, particularly in relation to medicines management.

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.

Staff worked collaboratively with health and social care professionals to make sure people received care that was joined up and met their needs. We received positive feedback about the service from a visiting health professional. They told us, ‘We (the registered manager and health professional) have worked well together on several difficult situations, communicating appropriately and ensuring that the resident and family are involved in the care planning process. Most importantly the residents seem happy and have a good relationship with the staff.’

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe living at the home. One person said, ‘I've been living in this home for about two years and I feel happy here. All my health concerns are addressed, and the staff seem safety conscious.’ Another person said, ‘‘I've been living here about 11 months. I feel safe and happy here with all my friends.’ A visiting healthcare professional told us, ‘I don't have any concerns around safeguarding or care in general.’

There were systems in place to record, investigate and report any safeguarding concerns. Staff had received safeguarding training and knew how to recognise and report episodes of abuse.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. Where risks to people were such that restrictions such as living in locked accommodation were necessary to ensure their safety, appropriate authorisations had been applied for.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s health and safety had been assessed and plans were in place to reduce the likelihood of harm. Risk assessments were regularly reviewed to ensure they continued to reflect people’s needs. One person’s care file contained out of date information about their special dietary needs to prevent choking. We asked for the correct information to be filed.

Equipment such as sensor mats, low bed frames and pressure relieving cushions were used to help minimise harm for those people found to have risks associated with mobility and tissue viability.

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.

Following our inspection in September 2025, we recommended the provider commission an up-to-date fire risk assessment and undertake any remedial work as a matter of urgency. A fire risk assessment was undertaken by an external organisation on 22 October 2025 and a number of recommendations were made, including the need for a compartmentation survey and additional fire extinguishers. At this inspection we noted that these had been completed, although not until June 2026.

The majority of regular safety checks to equipment and services had been completed. However, weekly fire safety checks had not been done for the 2 weeks prior to our inspection.

The service was set back from the road with an extensive well-kept lawn and surrounded by trees. However, this was not secure, so could not be accessed independently by residents. The only outside area which was secure was a concreted area to the rear of the property. Some attempt had been made to improve this with the addition of flowerpots and garden furniture. However, it was also the area in which people could smoke.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

All the required pre-employment checks had been completed before staff commenced employment at the service. Records included application forms, checks on employment history, right to work in the UK checks, health checks, references from previous employers and Disclosure and Barring Service (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff had received appropriate training and supervision.

People were happy with staffing levels. One person told us, ‘There are always staff on hand for me here, which is why I feel safe. Staff seem confident and competent at what they do.’ They went on to say, ‘The staff are kind and patient and they provide help quickly.’ Another person told us, ‘The daytime staff numbers seem to be okay, and they’ve always appeared to be well trained to me.’ A visiting health professional told us, ‘The staffing levels are good, and I have never had to hunt down staff.’ Our observations during the assessment confirmed appropriate staffing levels.

The provider did not always assess or manage the risk of infection.

Some areas of the home were not very clean. Skirting boards were dirty and some walls in the hall had splashes on them. Some radiator covers were dusty and dirty. The stair handrail felt sticky to touch and the paintwork on the banister was dirty. The dining room carpet was worn and stained. In one of the bathrooms, towels were stored on a shelf, where they were at risk of contamination. In another bathroom, residents’ toiletries had been left out on a shelf. Some of these same concerns had been raised in an unannounced inspection by the local authority Health Protection team in March 2026 and despite action being taken at the time, they had reoccurred. One visitor told us, ‘I think there's room for improvement with regards to cleanliness though.’ However, another visitor told us, ‘The home is clean, and her bedroom is very clean.’

Following our inspection of the service and a visit from the local authority quality monitoring team, the provider took steps to improve the cleanliness of the environment. We will monitor this at our next inspection.

Staff followed IPC guidance and wore the correct personal protective equipment (PPE) when needed. There was a good supply of PPE which was easily available. Staff had completed hand washing awareness and there was hand washing guidance in all the toilets and bathrooms.

The service had received a food hygiene rating of 5 from the Food Standards Agency on 30 March 2026.

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

We found ongoing concerns around the safe management of medicines which put people at risk of harm. Some issues we noted at our last inspection had been resolved. However, some concerns around medicines management, particularly in relation to time sensitive medicines, medicines records, stock balances and guidance for ‘as required’ (PRN) medicines continued.