Stoneleigh House

Updated 23 February 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This included checking the provider was meeting COVID-19 vaccination requirements. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Stoneleigh House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not currently have a manager registered with the Care Quality Commission. The previous registered manager had left following the last inspection. The lead senior care worker had taken over responsibility for running the home and told us they intended to apply for registration in the near future. The registered manager and provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

Due to the home experiencing an outbreak of COVID-19, we gave notice of our intention to inspect to ensure we had prior information to promote safety. Inspection activity started on 19 January 2022 and finished on 27 January 2022, at which point we had received all the additional information and clarification we had requested from the provider. We visited Stoneleigh House on 20 and 21 January 2022.

What we did before the inspection

Prior to the inspection we reviewed information and evidence we already held about the home, which had been collected via our ongoing monitoring of care services. This included notifications sent to us by the home. Notifications are changes, events or incidents that the provider is legally obliged to send to us without delay. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all this information to plan our inspection.

During the inspection

We spoke with three people living at the home about their experiences of the care and support provided. We also spoke with six staff members, which included the manager, area manager and care staff.

We reviewed a range of records relating to the safe and well-led key questions. This included four people’s care records, risk assessments, safety records, audit and governance information. We also looked at medicines and associated records for four people.

After the inspection

We requested additional evidence from the provider. This included information on partnership working, auditing and action planning, meeting minutes and training data.

Updated 23 February 2022

About the service

Stoneleigh House is a residential care home providing accommodation and personal care for up to 31 people within a large stone-built property, which has been converted and extended. There were 22 people living at the home on the day of inspection.

People’s experience of using this service and what we found

We found improvements were required with the management of medicines, the audit and governance process and the system for ensuring appropriate and safe staffing levels were deployed based around people’s needs.

People’s medicines were not managed safely, this included the management of stock and record keeping. People told us there seemed to be enough staff and requests for help were met in a timely way. However, the providers system for determining how many staff were needed to meet people’s needs, showed not enough staff had always been deployed. Staffing levels had been reduced in the afternoon and overnight. This reduction in staffing had not been risk assessed, to ensure it was safe.

We have made a recommendation about how the provider determines whether safe staffing levels are deployed.

The home had introduced a detailed audit and governance system, with a clear schedule in place explaining what would be assessed and when. However, the audit process had not identified any of the issues we found during inspection. There was no overarching action or improvement plan in place, to enable greater oversight of what needed to be addressed, who by and when.

We have made a recommendation about how the provider identifies and addresses actions and improvements.

People told us they felt safe living at Stoneleigh House. Risk assessments explained how staff could support people in line with their wishes, whilst keeping them safe. Staff knew how to identify and report safeguarding concerns, with training provided and refreshed. Accidents and incidents had been documented and reviewed to identify trends and help prevent reoccurrence. The necessary employment checks had been completed, to ensure staff were suitable to work with vulnerable people.

People and staff’s views were captured via meetings and questionnaires. People and staff spoke positively about the support they received and how the home was managed. Staff told us they enjoyed working at the home and had noticed improvements since the current manager had been appointed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 25 January 2021).

Why we inspected

We carried out a focused inspection of this service in November and December 2020 when breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do to improve safety and governance within the service.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. The local authority had also requested we inspect, in order to increase care home bed capacity within Oldham. The report only covers our findings in relation to the key questions Safe and Well-led which contain those requirements. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

You can read the reports from our last focused inspection and the previous comprehensive inspection, by selecting the ‘all reports’ link for Stoneleigh House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We have identified breaches in relation to the management of medicines and the audit and governance processes at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.