Stansfield Hall Care 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 that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to 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 environmental standards and safety and infection prevention and control measures.
 

This service scored 53 (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. Staff 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.
We found that incidents relating to the safe care and treatment of people were not consistently investigated or reported in line with regulatory requirements. Audits of accidents and incidents were either ineffective or not completed, preventing recurring themes and patterns being recognised and acted upon. This meant learning opportunities to help improve staff knowledge and skills were not provided ensuring best practice followed
 

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.
Assessments of people’s needs were not consistently completed. There was limited evidence to show the manager met with people and their relatives to establish the support required..

Staff worked closely with the local GP, who would make referrals to other healthcare teams where necessary. Staff said the GP surgery was supportive and would visit the home if needed
 

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

The provider was working with the local authority safeguarding and quality team to address issues raised with them.

Staff said they were able to raise concerns and had some understanding of the procedures to follow for the reporting of any accidents and incidents and safeguarding. However, records were not consistently maintained, and some accidents and incidents had not been referred to the local authority, ensuring appropriate action was taken to help protect people and keep them safe. Notification of events had not always been provided to CQC, as required by law.

Policies and procedures in safeguarding adults and Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) were in place. The information around DoLS was not always accurate, or up to date, and current guidance was not easily available for staff.
Applications to legally deprive people of their liberty had been made to ensure any restrictions on people were lawful. However, training records showed gaps, with some staff yet to complete essential training in safeguarding, MCA and DoLS ensuring people’s rights are protected and upheld
 

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.

Care records contained some generic and individualised risk assessments, which assessed risks to people such as the risk of using creams or risk of skin damage. People identified as being at an increased risk of falling had specialised equipment such as sensor mats in their bedrooms.

Environmental risks were not effectively monitored or managed to ensure the premises and equipment remained safe. We were aware that an inspection had been undertaken by Greater Manchester Fire and Rescue Service, which identified significant concerns. Immediate action was required by the provider to address the safety of the premises and ensure robust procedures were in place for staff to follow in the event of an emergency
 

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.

The service had been inspected by the fire service in September 2025. An enforcement notice was issued on the 6 October 2025 due to significant improvements required to ensure compliance with the fire regulations.

An up-to-date fire risk assessment was completed in October 2025. The level of risk was assessed as high, advising work required should be carried out within 1 month. We were informed the majority of work remained outstanding. This work was essential and should have been completed without further delay ensuring people living and working in the home were not placed at risk of harm. We were told work to address the concerns was to commence in January 2026. The provider was to submit an action plan of the work completed and progress made.

Effective systems were not in place to ensure the safety and suitability of the premises and equipment. Up to date servicing certificates were in place in relation to gas safety, small appliances and lifting equipment. However, information to confirm up to date servicing of the fire alarm, emergency lighting and outstanding work to the main electric supply were not provided. Further assurances were requested from the provider.

A review of records showed visual checks were carried out, including fire checks, water temperatures and calls bells. We noted window restrictors were not fitted in all areas and wardrobes had not been secured preventing an accident which may cause injury. This was discussed with maintenance staff, who confirmed necessary work would be completed.

The standard of accommodation was poorly maintained. Information provided showed some areas of the home had previously been decorated. Maintenance staff told us a number of bedrooms had recently been painted. However, we found some rooms appeared tired with old furnishings décor. The ceiling in a number of areas was heavily stained, and the conservatory roof required cleaning. We noted slide locks, which could not be overridden by the person, were fitted to a couple of bedroom doors. This was raised with maintenance staff.

The provider had not considered good practice guidance, creating a dementia-friendly environment to better meet people’s cognitive and sensory needs.
 

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.

Robust recruitment records were not maintained. We found application forms were not always fully completed and interview records did not demonstrate how suitability for the role had been determined. One personnel file contained only a single reference, and another appointment had been made by a relative, raising concerns about impartiality.

Opportunities for staff training, development, and support needed improvement. Training records provided were outdated and did not include an accurate up to date list of those staff currently working at the home. A review of records showed areas of mandatory and specialist training had yet to be completed or updated by some members of the team. Furthermore, regular supervision sessions and team meetings were not taking place, limiting opportunities for staff to reflect on and improve their practice.

A review of rosters showed adequate numbers of staff were available to meet people’s needs. Several staff members had worked at the home for a considerable length of time, providing continuity of care. People told us they received the support they needed from staff who were ‘mostly familiar faces.’ However, some people said at times staff were very busy, adding, “I'd say there are enough staff, however it can sometimes get busy at times" and “Under normal circumstances, there are enough staff. If someone needs the bathroom or changing though and they are 2 to 1 care, it can soon go awry.”
 

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.

Hygiene standards required improvement. The laundry area was too small to allow for designated ‘dirty’ and ‘clean’ zones, increasing the risk of cross-contamination.

We observed that a clinical waste bin was positioned in close proximity to the dining area. This presented a potential infection control risk and was not in line with best practice for the safe segregation and disposal of clinical waste.

Whilst looking around the home we found the sluice area was not kept locked. The hook and chain used to lock the room was broken. This area contained unlabelled cleaning liquids, which were easily accessible and were a potential hazard. The ceiling in the sluice was heavily stained, and items stored on the shelves were disorganised.

We reviewed the Infection Prevention and Control (IPC) checklist. This asked if hazardous substance were kept out of reach of unauthorised people and stored in a locked room when not in use. The findings recorded stated, ‘I can confirm this is the procedure, I cannot guarantee that this is adhered to 100%.’ There was no further information to evidence any action taken. Our findings demonstrated this had not been addressed.

A legionella assessment had been completed in February 2025. Action identified training required for staff. This remained outstanding. A review of training records showed that infection prevention and control (IPC) training was marked as ‘in progress’, with no evidence to confirm completion by staff. Managers confirmed this had yet to be arranged and would be added to the service improvement plan for 2026. This raised concerns about staff skills in implementing safe practices and maintaining compliance with infection control standards.

People and their relatives felt the home was kept clean. We were told, “The place is always clean, and my room is spotless” and “Its clean and the cleaners here are very good as well." Personal protective equipment (PPE) was readily accessible, and staff were observed using it appropriately while carrying out tasks, in line with infection prevention and control requirements.
 

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

Medicines were not stored securely. A suitable lock was required to ensure access to the medication room was restricted so only those staff responsible for the administration of medicines had access. This issue was addressed during our visit.

Systems were in place to ensure people received their prescribed medicines safely. Reviews of people’s prescribed medicines had been carried out by the GP. Records of administration were completed. However, we found records for medicines prescribed with a variable dose were not clear in relation to the dose administered. For ‘when required’ (PRN) medicines, such as pain relief medicines, protocols to guide staff were in place; however, these could be strengthened, particularly for those individuals unable to verbally request medication they may need.

One person was prescribed a thickening agent. This is used for people with swallowing difficulties to minimise the risk of aspiration. A review of records showed the prescribed dose was different from the dose being administered by staff. We were informed that the instructions had recently changed; however, the records had not been updated to reflect this. Immediate action was taken to address this and there was no evidence the person had come to harm.

Where care staff applied prescribed topical creams, a separate cream application chart was completed. Records included a body map to indicate the areas for application. A sample of charts were reviewed. We found evidence to show creams for 2 people were incomplete and did not demonstrate these had been applied as prescribed.

Daily stock checks of medicines were completed by senior care staff at each shift change, supporting safe management. Controlled drugs were stored securely and appropriately accounted for. People said they received their prescribed medicines. One person commented, "I get my medication when I should. They come with the little white box.”