Stonedale Lodge 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 inadequate. At this assessment the rating has remained the same. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Not enough improvements were found at this assessment, and the provider remained in breach of this regulation.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons learnt following accidents and incidents were not always actioned to keep people safe and promote good practice. For example, the providers systems for analysing events such as accidents and incidents did not always show actions to improve safety were completed in a timely manner. Thirty-eight falls had occurred between January 2025 and July 2025. Actions identified as part of the analysis to mitigate risk were not dated or recorded as completed, placing people at risk of experiencing repeated incidents. Another action identified on 19 May 2025 included the implementation of a falls management plan for a person who had experienced multiple falls. However, no falls management plan had been implemented.

The provider did not always work with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. For example, staff did not always follow guidance set out by other healthcare professionals to ensure people received safe care. Managers and staff failed to contact the district nursing team on 3 separate occasions for one person and on 1 occasion for another person following an increase in their health monitoring indicators which required input from healthcare professionals. Staff did not follow the pharmacist pathway for another person to ensure they received their medicines safely.

This is a breach of Regulation 12.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. For example, financial records for 7 people showed they had not received their weekly personal allowance which they were entitled to for some time. The provider failed to recognise this and refer allegations of potential financial abuse onto the relevant agency. Deprivation of liberty safeguard (DoLS), authorisations for some people had expired several months ago. Despite this, renewal applications were not applied for in a timely way to ensure authorised DoLS conditions remained relevant and lawful.

This was a continued breach of Regulation 13.

Staff did not always provide care to meet people’s needs that was safe. For example, care records for some people lacked guidance for staff on how to manage risks to people’s safety. One person required the use of a bed sensor to help manage the risk of falls, despite this there was no information recorded in the person’s risk assessment or risk management plan detailing the use of a bed sensor to mitigate the risk of falls. Another person’s toenails were significantly overgrown; their personal hygiene records dated 29 July 2025 recorded their toenails were checked by staff and no issues noted. Positional change records for another person were not always completed to evidence they had received the care they needed to mitigate the risk of skin breakdown.

This was a continued breach of Regulation 12.

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. For example, garden areas accessible to people posed a risk to their safety. Thorned shrubbery and weeds were excessively overgrown obstructing all pathways around gardens placing people at risk of skin injuries and trips, slips and falls. There was a build-up of moss and wet leaves on paving directly outside external fire exits making them hazardous. Sluice rooms containing hazards such as excessive water temperatures were left open posing a risk to people’s safety. Items of equipment in use to monitor people’s safety including sensor alarms and call bells failed to operate. There was a lack of robust safety checks to ensure equipment was in safe working order.We were assured immediate action was taken by the provider to make garden areas safe following us raising our concerns.

This was a continued breach of Regulation 12.

The provider did not make sure staff were safely recruited and received effective support, supervision and development. For example, staff did not always receive a consistent level of support through formal supervision or appraisal. Some staff confirmed they did not receive formal supervision. Recruitment processes were not always safe. A recruitment audit completed by a manager dated 20 May 2025 identified gaps in employment records and the action set to resolve this was recorded on 27 May 2025 as completed. Despite this recruitment records reviewed for 2 staff members showed gaps in employment with no explanation given and their application forms did not contain their full work history.

However, there were sufficient qualified, skilled and experienced staff. The staffing rotas showed the right amount of suitably skilled and experience staff were on duty across the home each day and night.

The provider did not always assess or manage the risk of infection. For example, some items of equipment used to support people’s safety and mobility were unclean including falls mats, hoists, stand aids and wheelchairs. The last infection prevention control audits across the home were completed on 30 April 2025, despite the providers governance framework stating these must be completed monthly. Actions set following the last audit required cleaning schedules to be completed, however, nighttime cleaning schedules commencing 23 June 2025 showed wheelchairs, hoists and stand aids were not cleaned during the entire week. Items posing a risk of contamination including multiple cigarette butts, a used incontinent pad and disposable gloves were discarded around gardens.

This was a continued breach of Regulation 12.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. For example, people were not always administered their prescribed medicines including creams because they were not always available in the home. When people should have been having regular monitoring of their health condition, this was not always done. On two occasions when the monitoring was completed and showed further action was needed, staff failed to follow the person’s care plan instructing them to contact a healthcare professional. When people were prescribed medicines to be given ‘when required’ there was not always person-centred information available to support staff to know when to give the medicines. There was not always information available to support staff to know which dose to give people who were prescribed a medicine with an option for a variable dose, such as one or two tablets. Medicines for disposal were not always kept securely in line with best practice guidance as set out in National Institute for Health and Care Excellence (NICE) Managing medicines in care homes. The providers medicines policy was not always followed; there was a lack of details included in the supporting information for people who were prescribed ‘when required’ medicines. The temperature of the medicines fridge was not always monitored in line with the providers policy, increasing the risk medicines were not always stored at the correct temperature. Medicines audits were not always completed at the required frequency and failed to identify medicines-related issues which had occurred. Records reviewed showed staff with responsibilities for medicine management had not always completed the required medicines training and had their medicines competency assessed.

This was a breach of Regulation 12.