Stoneyford 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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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. Staff completed incident forms when accidents happened, these were regularly reviewed by the registered manager to ensure any identified risks were mitigated and learnings were shared with staff members. We saw staff receiving updates about lesson learned through minutes of staff meetings and supervision records. This ensured people remained safe and best practice was embedded consistently with all staff.

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. For example, on the day of assessment we saw a person being supported to a hospital appointment by a staff member. Staff worked in partnership with the hospital transportation team to ensure the persons needs were communicated and staff attended the appointment with the person. This was facilitated by the provider who ensured extra staffing levels during the day to accommodate the staff member being away from the home.

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. The management team kept a log of all notifiable incident that were reported. Where the assessment team identified a potential incident that had not been reported appropriately this was immediately investigated and rectified and measures put in place, including upskilling of staff on what incidents need to be notified to the CQC and local authority.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Some MCA assessments were not always detailed or person centred. However, everyone who needed a DoLS either had this in place or an application had been made appropriately to the local authority to seek this authorisation. This ensured people were not deprived of their liberty despite the current MCA assessment quality. The compliance manager took immediate action and organised additional training for the management team and assured all MCA assessments were updated.

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. Risk assessments were completed and reviewed regularly to ensure risk remained relevant and mitigated, and potential new risks were identified. We saw tools such as Malnutrition Universal Screening Tool being used to identify people at risk of malnutrition and Waterlow tool to identify people at risk of developing pressure damage. Where these tools identified people were at risk the provider had appropriate care plans and support in place to mitigate these risks.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The home was continuously monitored and maintained by a maintenance team who had an ongoing action plan which meant people remained safe within the environment. People told us there was enough staff to support them and they felt safe. One person said, “The staff are lovely and come when I need them.” Another person said, “I don’t have to wait long if I press my call bell.”

The provider made sure there were enough qualified, skilled and experienced care staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. However, the manager was open and transparent about the recent challenges they had experience in recruiting and performance for areas such domestic, laundry and catering. While there was no evidence anyone had sustained any harm from this shortage, the manager acknowledged that standards were not always to the desired level. People and relatives, we spoke to told us this impacted them slightly. For example, 1 relative said, “I noticed my [relative] didn’t have clean socks, I asked staff and when they eventually brought a pair, they were odd.” Another person said, “My room isn’t as clean as it used to be, I see [care] staff trying to help while they look for new staff.”

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.

We observed staff wearing personal protective equipment (PPE) such as gloves and aprons, however staff failed to change PPE between tasks. For example, we observed a staff member wearing gloves while supporting a person with their nutrition. This staff member then assisted a person who had dropped a dirty item onto the floor. The staff member failed to replace their PPE before they continued support the person with their nutritional needs. This practice placed people at the risk of harm from contamination and the risk of spread of infection.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People received their medicines safely and where needed, timed medicines were safely and effectively administered in line with people’s health conditions. The manager and senior care staff undertook regular audits. This meant the management team had a thorough overview of standards in the home and were able to monitor and identify issues or gaps in records or competency quickly which kept people safe from the risk of harm.