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, and the provider remained in breach of this regulation.

This service scored 31 (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 actioned to keep people safe and promote good practice. For example, incidents were not recorded on the providers monthly system for analysing and learning lessons from events. Care records showed 6 falls had occurred in the month of September 2025 and only 3 of them were entered onto the providers system. In September 2025, an allegation of abuse was raised with the local authority safeguarding team following an altercation between 2 people, however, there was no record of this incident on the providers system. In addition, an incident we observed involving 2 people was not recorded including the action taken to reduce further risk.

The provider did not work effectively with people and healthcare partners to establish and maintain safe systems of care in which risks were properly managed and monitored. For example, staff did not consistently follow safe pathways designed to ensure people received appropriate care and treatment. Managers and staff did not maintain accurate and up‑to‑date records to reflect an injury sustained by one person. As a result, the person did not receive the timely medical treatment they required, which led to the need for urgent intervention.

The provider did not work effectively with people or healthcare partners to understand what being safe meant to them or how to achieve this. There was insufficient focus on improving people’s lives and protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. For example, the provider did not always share concerns promptly or appropriately. Although safeguarding referrals were submitted to the local authority safeguarding team, we were not assured there was robust management oversight of all referrals. The home manager did not have access to records of all safeguarding referrals made. They provided a safeguarding file but explained, until five weeks ago, the former deputy manager had kept safeguarding records on their computer, which they were currently unable to access.

We observed a person with an open wound that had not been identified or reported by staff. This was despite records stating staff had assisted the person with personal care that morning. Following our intervention, a GP reviewed the person and confirmed the wound was infected. Antibiotics were prescribed, and the home manager raised a safeguarding referral for an allegation of neglect.

However, systems and processes had been strengthened to ensure the safe management of people’s finances and personal possessions.

The provider did not work with people to understand and manage risks to their safety. Care records did not consistently reflect current risks or how these should be safely managed. For example, 2 people’s falls risk assessments and care plans had not been updated following multiple falls. This meant their level of risk was inaccurately assessed, placing them at increased risk of avoidable harm. There were inconsistencies in another person’s care plan relating to a known risk of skin breakdown. In addition, the care records for another person did not provide an accurate description of a current wound. This person was known to be at risk of developing a pressure injury and had developed a blister on their leg. Staff did not monitor this risk in line with the person’s care and risk management plan, which resulted in the deterioration of the wound.

The provider did not always identify and manage potential risks within the care environment, to ensure the consistent delivery of safe care. For example, during our review of visitor books on both units, we found not all visitors had signed in on entering and leaving. This compromised security and posed a risk to visitor safety in the event of emergencies such as fire evacuation. Two frequent visitors we spoke with confirmed they had not signed in that day and stated they often did not do so. We observed 3 healthcare professionals visiting people on the units who had not signed the visitor book on arrival or departure.

Parts of the environment placed people at risk of harm. We observed doors left open to bedrooms undergoing refurbishment, which contained hazardous items including electric tools and paint. These areas were secured after we raised the concern.

There were, however, improved systems in place for checking the functionality of equipment such as sensor mats and call bells. Call bell audits were now routinely carried out, and daily checks had been enhanced to ensure airflow mattresses were inspected each day. Records showed however, these checks had not always been completed, and the process required further embedding.

All essential health and safety certificates for the environment, equipment, and facilities were up to date.

The provider did not make sure there were enough suitably skilled and qualified staff to safely meet people’s needs. For example, training records showed that 19 staff had not completed pressure ulcer prevention training. This included five of the six staff caring for a person whose wound had gone unnoticed, placing them at risk of avoidable harm. The provider used a dependency tool to calculate safe staffing levels based on people’s assessed needs. Despite this, staffing rotas and feedback from staff showed the number of staff working on each shift across both units regularly fell below the provider’s own safe staffing levels. Staff told us they did not feel there were always enough staff to meet people’s needs in a timely way. They reported being short staffed, rushed, and under pressure. Staff comments included, “Low staffing levels at times,” “Very rarely take breaks lately, not had one today,” “Not enough staff for the needs of the residents. We just don’t get time to sit and chat to the residents” and “Residents are left waiting because there’s not enough of us to get to them.”

Recruitment processes had improved overall. However, recruitment records for a recently employed member of staff showed gaps in their employment history that had not been explored. This was despite the interview documentation including a section prompting the interviewer to review and discuss any gaps.

The provider did not effectively assess or manage the risk of infection. For example, equipment used to support people’s safety and mobility was unclean. This included toilets, commodes, falls mats, wheelchairs, pressure‑relieving cushions and water jugs. Items of personal protective equipment (PPE), such as disposable gloves and aprons, were stored in unclean drawers in bathrooms alongside people’s personal toiletries, increasing the risk of contamination. Clinical waste was disposed of in bins without the correct colour‑coded liners, and the foot‑pedal mechanisms on some waste bins were broken. These infection prevention and control (IPC) concerns had already been identified by the local authority following a quality monitoring visit completed prior to our visit. IPC audits were not effective in reducing the risk of infection. An IPC audit carried out across both units in October 2025 identified issues with the condition of domestic and clinical waste bins, as well as unsafe disposal of clinical waste. Despite these concerns being raised, we observed they remained outstanding, and no action had been taken to address or rectify them.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. For example, medicines were mostly administered at the correct times. However, we found one person had not received their medicine before other medicines and food, as required by the prescriber’s instructions.

Information about people’s medicines preferences was recorded, and when people were prescribed medicines to be given ‘when required’, there was usually a plan in place to guide staff on their administration. However, when people were prescribed two medicines for the same condition, such as constipation, these were not always linked within the care records. This created a risk people may not receive the most appropriate treatment.

We identified several concerns about the safe storage of medicines, including controlled drugs. These were raised with managers, who took immediate action to address them.

Fluid thickeners prescribed to people at risk of choking were not always accurately or consistently recorded, placing people at unnecessary risk. Fire risks associated with prescribed creams were not always fully assessed, as staff had not completed the relevant risk assessments correctly. One person prescribed a transdermal patch did not have appropriate checks in place to ensure the patch remained in situ each day.

However, improvements had been made to the systems for ordering medicines. When stocks were low or had run out, appropriate action was taken promptly. Staff had received medicines training, and competency assessments were detailed and up to date. Medicines audits were now carried out regularly. Audit outcomes varied month to month, with recent audits identifying shortfalls in several areas that required further action to ensure medicines handling was safe.