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 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 38 (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 demonstrate a safe learning culture, as incidents did not consistently lead to timely reviews or updates of people’s care plans. For example, a care plan to manage the risk of choking for a person was not implemented until 27 January 2026, despite the choking episode and hospital admission occurring in November 2025. Accident and incident records were not completed consistently, and gaps in detail and follow‑up actions remained, despite the provider identifying these issues through their own monitoring systems. Some incidents were not recorded on the electronic care planning system (PCS) at all, increasing the risk they would not be reviewed or lead to necessary preventative measures. The provider had not fully learned lessons from the previous inspections, with repeated issues in incident management, record accuracy, medicines management and governance.

The provider did not establish or maintain safe systems, pathways and transitions of care. For example, inaccurate and inconsistent records did not provide a reliable basis for safe decision‑making or effective information‑sharing. Care plans, risk assessments and monitoring records were not consistently updated, to ensure staff had current and accurate information to inform safe decision making. If a person required hospital admission or support from external professionals, the information available would not always have accurately reflected their needs, risks or recent health changes. This increased the likelihood other services might not receive the essential information needed to continue safe care and treatment. The inaccuracy of records hindered effective partnership working. External professionals experienced difficulties obtaining clear, up‑to‑date information needed to support their assessments and decision‑making.

The provider did not always work 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. For example, although a system was in place to ensure safeguarding referrals were submitted to the local authority, this was not always used consistently. Some low‑level incidents did not appear on the safeguarding log and had not been recorded on the electronic PCS system. This increased the risk safeguarding concerns might not be identified, reviewed or escalated appropriately.

However, the overall system for submitting safeguarding referrals was effective, and referrals were generally made when required. Staff were up to date with safeguarding training, with 98% compliance recorded. People we spoke with told us they felt safe and well cared for.

The provider did not work with people to understand and manage risks to their safety. For example, care records did not consistently reflect people’s current risks or how these should be safely managed. Records used to support the management of risk were not always complete or accurate and did not always reflect people’s current needs or risks. This increased the risk people could receive unsafe care. One person’s nutrition assessment stated they had ‘no difficulties’ with eating, chewing or swallowing and were on a regular diet. However, their current care plan recorded they required a modified diet due to a risk of choking. Another person’s care plan had not been updated to reflect a deterioration in their mobility. Staff reported the person now required assistance from two members of staff, rather than one, yet this change had not been recorded in their care plan.

Items of food and drink were available in the dining room for people to help themselves. Four people required modified food and fluids due to a risk of choking, and 2 of them were independently mobile and able to access the dining room without staff supervision. Consideration had not been given to how these people could safely avoid consuming food or drinks unsuitable for them, increasing the risk of harm. The food and drink were removed from the dining room immediately after we raised this.

The provider did not always identify or manage potential risks within the care environment to ensure the consistent delivery of safe care. For example, although no significant environmental hazards were found during this assessment, systems designed to identify and address risks were not followed consistently. Daily walkarounds were not completed each day as required, and those completed contained gaps, including missing sections and a lack of recorded actions to address concerns identified. Not all visitors had signed the visitors’ book on entering and leaving the units, posing a potential security risk in the event of an emergency. This was a repeated concern from the previous inspection.

However, valid certificates were in place confirming essential health and safety checks on equipment and utilities had been completed by competent persons at the required intervals.

The provider did not ensure staffing arrangements were safe or reflective of people’s needs. For example, the dependency tool used to determine staffing levels did not accurately reflect the number of staff available to deliver direct care. Although dependency scores were based on care tasks undertaken by care staff, senior care staff with supervisory responsibilities were included when calculating the overall staffing numbers. This meant the number of staff deployed was not always sufficient to meet people’s needs and keep them safe. Staff told us they were often understaffed, which affected the accuracy of record‑keeping and reduced the time they could spend with people. Staff comments included, “Definite staffing issues”; “People here are a falls risk and it’s not safe with fewer staff” and “Just not enough of us.”

A member of staff was required to be present in the lounge and dining areas to provide oversight and support. We observed these areas left unsupervised for periods of up to 10 minutes increasing the risk staff would not be able to respond promptly to incidents, changes in people’s needs or emerging risks.

The provider did not always effectively assess or manage the risk of infection. Although some improvements had been made to infection prevention and control (IPC) practices, several concerns remained. For example, on day 1 of the inspection, the outside enclosure used to store clinical waste bins was unlocked, and the clinical waste bins inside were unsecured, allowing unrestricted public access to hazardous waste. We raised this with a manager, but the same issues were found unchanged on day 2, one week later. We found multiple items of equipment used to support people with their mobility and safety, including wheelchairs and falls mats, to be unclean. This was a repeated concern from the previous inspection.

However, there were sufficient clinical and domestic waste bins in bathrooms and toilets lined appropriately to support the safe disposal of waste. There was a good stock of PPE available across both units, and it was stored separately from other items to prevent contamination.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. For example, medicines were generally available to be administered, and records showed medicines were given to people as prescribed. However, one person experienced a delay in being given their prescribed antimicrobial to treat an infection, there was a risk their condition might have deteriorated.

We saw medicines to be given at specified times were given on time, however, a medicine that should be given before all other medicines and food, was not given correctly and in line with the manufacturer’s directions, this meant the person might have experienced side effects and the medicine might not have worked properly.

When people were prescribed topical preparations such as creams, information to support staff to know where to apply the creams was not always available, and records did not show creams were always applied as prescribed. There was a risk people’s skin might not be cared for properly.

When people were prescribed ‘when required’ medicines, we found there was usually information to support staff to know when to give the medicines. However, when there was an option to give a variable dose, for example 1 or 2 tablets, there was not always information to support staff to know which dose to give. We found when people were prescribed more than one medicine for the same condition for example to treat constipation, there was not always information to support staff to know which medicine to give in preference to the other.

Records for one person showed the required health monitoring was not always taking place as detailed in their care plan. This meant there was a risk they might experience a deterioration in their health that staff would not be aware of or able to escalate appropriately.

The provider completed audits; however, the audit process did not always identify the issues found during the inspection.