During an assessment under our new approach
Date of inspection: 15 August and 29 August 2025. Stone Gables Care Home is a residential home providing accommodation for persons who require personal care, some of whom are living with dementia. During this assessment we looked at all quality statements. The service was providing regulated activity to 31 people at the time of the assessment.
At our last inspection, 28 July 2023, we rated the service as requires improvement. We found medicines were not always safely managed, and risks were not consistently assessed. The provider was in breach of the legal regulations relating to safe care and treatment.
At the same inspection, we found systems and processes for monitoring and improving quality, and systems for monitoring and reducing risks were not always operated effectively. The provider was in breach of the legal regulation relating to governance.
We carried out this assessment to check whether improvements had been made since the last assessment in July 2023. At this assessment we found that the provider had made some improvements to the management of medicines and risk. However, we found that not enough improvement had been made, and the provider remained in breach of the legal regulation relating to safe care and treatment.
The provider had introduced quality assurance systems but these had not been fully embedded. We continued to identify areas requiring improvement, and the provider remained in breach of the legal regulation relating to governance.
We have asked the provider for an action plan in response to the concerns found at this assessment.
There were enough staff with the appropriate skills, qualifications and experience. However, at times staff and people told us they felt the home was short staffed. Staff described how they protected people from abuse and how they would report concerns. Staff had training on how to recognise and report abuse, and they were confident in applying this knowledge.
Care plans and risk assessments were not always person centred as key information was sometimes missing from care files. Some risk assessments and accredited tools had not been completed to monitor outcomes. Although we found gaps within risk assessment records staff knew people’s needs and supported people safely. We identified some people’s needs were not met in respect of management of their skin integrity, personal hygiene, nutrition and hydration. This was mainly due to poor record keeping.
People were treated with kindness, empathy and compassion, and staff respected people’s privacy and dignity. The provider cared about and promoted the wellbeing of their staff and staff told us that improvements had begun to be made. One staff member said, “Things are getting better.”
A new management team had recently started to make improvements within the home and were receptive to the feedback given at the assessment. The provider had also taken steps to make improvements by hiring a consultant to develop new ways of working.