Stretton Hall Nursing 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. This is the first assessment for this service with the new provider. Previously with the old provider safe was rated requires improvement. At this assessment the service continues to be rated requires improvement for safe.

This assessment has found the provider to be in breach of regulation 12 (Safe care and treatment). An action plan request will be submitted to the provider.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The manager adopted an inclusive learning model which included the staff team, Operations Director and internal quality team. Where accidents and incidents took place, staff documented the incident in detail and this was followed by a manager review which identified any actions or control measures required. The management team involved nurses and all staff members in the review of accidents and incidents. The manager had recently had an influx of concerns to investigate and work through, which they investigated individually and a detailed report of findings with any actions was created. The manager then reviewed actions regularly.

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. The provider had an internal quality team who worked with the manager and supported them in identifying and achieving improvements for the service. Quality assessments completed internally were guided by Care Quality Commission’s regulations to ensure the service kept up to date with current legislation. A report and action plan were provided to the manager following the quality check. The service was supporting people who had been discharged from hospital. The management team ensured any referral sent to them was fully assessed, including checking staff had appropriate skills to meet people’s needs. The provider undertook a detailed assessment of people’s needs prior to people moving into the service, recording personal characteristics and information about their health background.

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 understood their duties and responsibilities in reporting safeguarding incidents to the Local Authority and the Care Quality Commission. The manager completed thorough investigations and ensured people were safeguarded. Staff were trained in safeguarding. Staff we spoke with were clear on the process of reporting safeguarding concerns and were fully trained in safeguarding.

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

things that mattered to them.Care plans and risk assessments were detailed in identifying potential risks to people. The service had good oversight of people’s needs which were detailed in monitoring charts. For example, where people had required monitoring due to risk of malnutrition, this was completed in detail and discussed at the daily flash meeting.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. During our assessment we were made aware by the Operations Director and manager of the improvement plan to improve and renovate the home’s appearance. We saw evidence where the home had recently undergone decoration and areas where furniture had been replaced with new items. The home was clean and had dedicated cleaning teams. Some storage rooms required a reduction of items stored in them to reduce the risk of fire. The manager agreed and developed an action plan which included clearing storage rooms.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, some people and staff felt the staffing ratio was not enough to provide all the care required. We raised this to the Operations Director and manager. They evidenced a live staffing dependency tool which changed to meet people’s needs. Through investigation, it was found to be an issue of where staff were deployed around the home, rather than not having enough staff. As a result, we saw people had a poor experience during their lunchtime meal. For example, we observed one person banging their cup on the table whilst waiting for their meal, they then became more distressed and physically contacted another person sitting at the table with them. Staff not being deployed effectively put people at increased risk of harm. The Manager and Operations Director told us they would prioritise positioning of staff to ensure enough staff were present in the different areas of the home to ensure people’s needs were met safely.

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 home had a dedicated domestic team who completed cleaning regularly throughout the day. Staff had access to Personal Protective Equipment (PPE) with PPE stations consistently found around the home. Cleaning schedules were completed daily. Infection control audits were completed and overseen by management. People we spoke with told us, “Staff always wear gloves and aprons”. One person told us, “I do see staff washing their hands before helping me”.

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. Staff were kind and caring when interacting with people and provided support during medicines administration. However, staff did not always follow the prescriber's instructions when administering medicines. For example, a medicine was given with food instead of before, which may have reduced how well the medicine worked.

Medicines were not always managed safely. We found medicines no longer prescribed to people were not disposed of. This created a risk of the incorrect medicines being administered. Open date labels for liquids and eye drops were not always recorded. We found excessive medicine stocks, with multiple boxes of medicines used at the same time, increasing the risk of stock errors. One eye drop and one liquid medicine had expired, but they had not been segregated from stock still in use. This meant the service could not be assured these medicines had been effectively administered.

Medicines were stored in fridges where maximum fridge temperature had been recorded outside the recommended range on some occasions. It was not clear whether action had been taken, as a repeat temperature reading was not documented on the monitoring sheet. In addition, several entries for September 2025 were missing for another medicine fridge. However, the missing temperatures had been identified during a medication audit by the provider. The manager told us they had raised this issue with staff prior to our visit and would raise again the importance of recording temperatures.

Where when required (PRN) medicines were prescribed and administered, protocols were mostly in place. We found one example where a PRN protocol was missing for a medicine. However, the PRN protocols were not always person-centred. We saw examples where the rationale and outcomes were not always assessed or recorded when a medicine was given. People’s care plans did not always have detailed information regarding how to support them with their medicines. For example, a person with high blood pressure did not have a blood pressure care plan. A care plan for a blood thinner had 2 different medicine names for the blood thinner in the same care plan. A person on end-of-life medicines had no mention of this in their care plan. This lack of clear guidance for staff placed people at risk of medicines not being administered as required and put people at increased risk of harm.