Stone Gables 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 requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 56 (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. Throughout our inspection the staff told us the team were supported and learnt lessons from incidents. Staff listened to concerns about safety and investigated and reported safety events. One staff member said, “If there is an incident or accident, they will call 111, ring the family and complete incidents and accident form.” Incident and accidents were recorded and actions followed up. People and their relatives told us incidents were managed safely and actions taken when required. One relative said, “We have no worries about safety. [Person] fell about 10 days ago in the night, staff rang me in the morning to tell me about it.”

The service was working with people and health care partners to make improvements and establish safe systems of care. For example, they had implemented a new electronic recording system. However, there were discrepancies and gaps within records which meant that people could experience inconsistent care and risk management. Some risk assessments had been completed on the electronic system however, staff did not have access to these, and they had not been put in people’s care files to guide staff. We looked at 4 people’s repositioning records and found these had not always been completed. These shortfalls meant that the systems in place may not be working effectively.However, the provider supported people to move into the home safely. Assessment plans were carried out to ensure people’s needs could be met prior to them moving into 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.

Safeguarding concerns were appropriately dealt with, and action was taken by the management team to reduce risks to people. Staff knew how to report concerns and people told us they felt safe living at Stone Gables. Comments included, “We are looked after, it’s why I feel so safe”, “People treat you like a friend, so you feel safe.” Relatives also told us they felt their loved ones were safe, with comments including, “Yes, [Person] is safe; compared to being at home.”

Whilst people told us they felt safe and secure, the provider did not always work well to understand and manage risks, due to improvements needed to systems for completing care records. Care plans and risk assessments were stored partly on an electronic system and partly on paper. On the first day of our assessment, we found that some people did not have risk assessments in any of their care files. For example, 1 person at risk of falls did not have a falls risk assessment to guide staff in reducing this risk. Another person, who was at risk of skin integrity issues, did not have a risk assessment in place to support safe care.

Although we found issues within risk assessment records staff knew people’s needs and supported people safely. We observed a staff member supporting a person to move from their wheelchair to a chair. The person was reluctant and appeared fearful. The staff member was positive, reassuring and kind, giving loud, clear instructions and support. This was repeated until the person moved safely to the chair.

The provider did not always identify and manage potential risks in the care environment. During our walk around of the home we found several areas that required improvement. For example, bathrooms did not appear thoroughly cleaned. Toilet handrails on the ground floor were loose and needed to be tightened to ensure they were secure. At times it was difficult to determine where people’s rooms were as some doors had numbers missing and not all doors had names to show where people’s rooms were. The provider was in the process of arranging for this to be completed.

The provider did not always ensure equipment, facilities and technology supported the delivery of safe care. We found equipment in hallways that could pose a risk to people at risk of falls. On our first day of assessment, some people who required sensor mats did not have them in place. On the second day the provider told us new sensor mats had arrived and would be put installed.

Personal emergency evacuation plans (PEEPS) outlined the levels of support people would require in the event of an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, feedback from people, staff and our observations showed staffing levels were not always sufficient.

Our observations identified staff were not always present in the communal areas and staff appeared busy throughout the day. Although the activities co ordinator was in the communal area there was an incident were a person felt breathless and there was no care staff to support at the time.

We received mixed feedback from people and their relatives about staffing levels. Comments included, “I think they are a bit short of staff; there are less staff now than there were” and “There are not as many staff now, and they seem pushed and sometimes they have to cook. Other people and relatives told us, “There is always someone about and we don’t have to wait long for them to come. There’s enough staff when I am here.”

Staff told us they were often short staffed. Comments included, “When we are short staffed sometimes residents are neglected. Many times, staff had raised their concerns regarding staff levels, sometimes they book agency, and they don’t turn up” and “I don’t think they have enough staff due the needs of the residents.” The provider was aware of the staffing concerns and had recently increased their staffing levels.

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. During our inspection of the home, we found areas that were unclean, including communal areas and bathrooms. An infection prevention and control audit was carried out with the local authority, which identified areas requiring improvement, resulting in a compliance score of 72%.

People were not always supported to maintain their own personal hygiene in line with their needs and preferences. One person told us they had not had a bath for some time. When we checked, they had been given body washes but had not received a bath for a period of 2 months. This posed a risk as the person had a catheter in place which requires regular cleaning to prevent against infections.

Staff did have access to personal protective equipment (PPE), and we observed staff appropriately washing hands and using PPE during care tasks.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. At our last assessment the provider had failed to ensure medicines were managed safely. At this assessment we found some improvements had been made however, there were still some shortfalls. For example, 1 person was prescribed a time sensitive medication which had not been administered at the correct time. Another person was prescribed paracetamol 4 times daily; however, staff had not always recorded the times of when this was given to prevent an overdose. One person required thickener in their drinks however, staff had not recorded when this had been given.