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 changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (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.

The provider demonstrated a willingness to learn and improve by working with the Local Authority and engaging with external feedback. We found evidence showing the service responded appropriately when concerns were identified and took actions to address recommended improvements. The provider was responsive to feedback from CQC and provided assurances actions were being taken, for example implementing sensor mat checks and amending ‘as and when’ medicines (PRN) protocols to strengthen safety.

Learning at the service was often reactive rather than proactive. The provider’s quality assurance and governance systems did not identify areas for improvement at an early stage, or issues were identified following external review rather than through internal monitoring. This meant opportunities to address risks and improve practice were not always recognised promptly

The service actively sought feedback from people about their experiences of the service through meetings and questionnaires. This demonstrated an understanding of the importance of involving people in service development and learning from their views. For example, communal spaces had been decorated in line with people’s preferences, and changes had been made to the menu following feedback.

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.

Care plans were up to date, person‑centred, and reflected people’s current needs. These included health‑specific care plans, which provided staff with clear guidance on how to support people safely with identified health conditions.

Hospital passports were in place for people using the service. These contained important information about people’s health needs, routines, communication preferences, and risks, helping to support safe and effective care if people required hospital treatment or input from other healthcare services.

Appropriate risk assessments were in place and regularly reviewed. These supported staff to understand identified risks and the actions required to reduce harm while enabling people to maintain independence.

We found evidence of effective partnership working with external healthcare professionals. Records demonstrated involvement from district nurses in supporting people with diabetes management, which helped ensure people received timely clinical input and continuity of care.

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 we spoke with during our assessment told us they felt safe at the service. Safeguarding concerns were raised with the local authority when required, and statutory notifications relating to safeguarding alerts were submitted to CQC in line with reporting requirements. The service had a safeguarding policy in place which outlined actions staff should take when abuse is suspected or disclosed.

We reviewed the training matrix that showed all staff had completed safeguarding training. This indicated staff received the guidance to recognise and report signs of abuse or neglect. Staff we spoke with demonstrated a good understanding of safeguarding. They were able to describe different types of abuse and clearly explained the steps they would take if they had concerns.

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.

We found evidence showed people were actively involved in safely managing risks while taking part in everyday life and community activities. People were supported and encouraged to engage in activities meaningful to them, such as swimming, visiting local shops, and spending time at the local pub, with appropriate consideration given to safety and individual needs.

The service promoted positive risk taking, enabling people to maintain independence while ensuring necessary safeguards were in place such as appropriate staff support. Days out were planned and discussed with people during resident meetings, giving them an opportunity to contribute to decisions and understand the associated risks. These outings included visits to cities, seaside locations, local attractions and museums.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We observed the home to be uncluttered, and communal areas were clean and tidy. Decoration throughout the service reflected the preferences and individuality of the people who lived there, helping to create a homely atmosphere.

Some areas of the environment appeared tired, with signs of wear and tear noted in places, including one communal bathroom. However, there was evidence the provider had recognised these issues and had taken action to address them. Improvements had already been made, including the refurbishment of a second communal bathroom and communal toilets, and communal areas had been redecorated.

Records showed environmental and equipment checks were up to date, including routine safety checks of equipment used within the service. This helped to ensure the environment remained safe and reduced risks to people who lived there.

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.

The service used a dependency tool which was completed by the management team to assess staffing requirements and support effective workforce planning. During our assessment the home had sufficient staffing, any gaps were managed effectively. Where required, agency staff were used to maintain continuity of care, and structured agency induction arrangements were in place to ensure staff were familiar with people’s needs and the service’s expectations before providing support.

People we spoke with told us they felt staffing levels were sufficient to meet their needs. One person told us, “The staff are good, I think there are enough staff on duty.”

The service had a training matrix in place that demonstrated staff received a broad range of training to support them in their roles. This included mandatory training alongside health specific training such as diabetes, epilepsy, and catheter care, which supported staff to deliver safe and effective care. Staff had also completed learning disability awareness, autism training and had either completed or were in the process of completing ‘Oliver McGowan’ training.

Recruitment processes were effective, and staff were recruited safely, helping to ensure people were supported by suitable and appropriately checked staff.

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.

The service demonstrated safe infection prevention and control practices. During onsite visits, staff were observed wearing appropriate personal protective equipment (PPE) when supporting people. One person told us, “The staff wear gloves and aprons when they help with washing and dressing.” Staff spoken with demonstrated a good understanding of infection prevention and control measures, including the correct use of PPE, effective hand hygiene, and actions to take to prevent the spread of infection.

Relevant infection prevention and control policies and procedures were in place. These provided clear guidance for staff on the appropriate steps to take to prevent the spread of infection, including the use of PPE and hand hygiene. This provided assurance that robust systems were in place to protect people and staff from the risk of infection.

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

Medicines were stored securely, and appropriate arrangements were in place to restrict access to only authorised staff. Medication Administration Records (MAR) did not indicate any recorded medication errors. However, a discrepancy was identified when stock balances were checked, with one medicine showing a higher stock level than recorded. This meant the provider could not be fully assured medicines were always being administered as prescribed. In addition, medication counts were not consistently kept up to date, which increased the risk of medicines errors and reduced oversight. The concerns regarding medicine records had not been identified by staff or management. This was shared with the registered manager who advised they would be taking steps to address the concerns.

Protocols were in place for medicines administered on an ‘as and when required’ (PRN) basis. However, these lacked sufficient detail, particularly in relation to guidance on actions to be taken by staff where PRN medicines were required over prolonged periods. This reduced assurance that PRN medicines were being used in a safe, consistent, and person‑centred way. During this assessment the registered manager provided assurances that PRN protocols had since been reviewed and updated to reflect actions to take.