Stoneyford 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

During our assessment of this key question, we found concerns around safe care and treatment which resulted in a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During our assessment of this key question, we found concerns around premises and equipment which resulted in a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People did not receive their medicines safely or in line with best practice. We observed infection prevention and control and hygiene concerns within the home including urine-soaked bedding within a bedroom. Communal areas of the home were unsupervised for large periods of time with no system in place for people to contact staff or raise awareness when they required support, including in emergency situations. People told us they had repeatedly raised these concerns but no action had been taken.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People we spoke with told us they had raised concerns with staff and the management team but had had not received outcomes to these concerns or experienced any improvements in their care. One person told us they and their relative had requested to speak to a senior member of staff to raise concerns but the senior on duty had refused to speak with them. Another person said, “Nothing changes, even when you tell staff about an issue it doesn’t get put right. I know they care but I think their hands are tied and they would change it if they could.”

The management team told us there were regular staff meetings where incidents were discussed and best practice was shared, however staff said they did not receive competency checks or individual supervision on a regular basis and were not provided with feedback on their performance for areas of improvement.

We reviewed the provider’s comments and complaints and accident and incident forms and whilst incidents and feedback were being recorded there were no outcomes or improvement actions recorded. This meant the management team did not have oversight or a monitoring and evaluation system in place to ensure lessons were learned and shared with staff.

People told us they didn’t always feel safe with pathways and transitions undertaken in the home such as admissions. One person said, “Just lately people have been admitted who seem to have very high needs, I don’t think they should be here it’s not safe.” Another person said, “I’m frightened, I’ve tried to tell managers my concerns about people before. I won’t do that again as they take it out on you by ignoring you.”

Staff raised concerns that people were not always assessed correctly and this affected the care they received. One staff member said, “We have had people admitted to the service who really needed one-to-one care for their safety, this puts pressure on the staff team as we can’t provide this.” Another staff member said, “We have been told to alter people’s notes to show care takes longer than it does to support them with things like personal care, I don’t know why but I refused. Then I was removed from supporting that person.”

Partners who worked with the home and management team told us there were inconsistencies in how people were treated within the home. For example, a professional who worked with the service said, “One person was deemed by the home as needing nursing care however a referral for support was not requested. We were made aware when the person was served notice, we assessed the person, and they did not meet the criteria for nursing care however the home would not work with us to adapt the care plan to allow the person to remain living at Stoneyford Care Home.”

We reviewed the latest admissions and spoke with all members of the management team about the inconsistencies described by people, staff and professionals. The management team acknowledged what professionals had told us but stated this was a decision of the provider and not a decision based on their assessed needs. Records showed there had been an unsafe admission to the home for a person with mental health needs. Training records showed staff did not have the skills to support this person appropriately or safely. This placed the person and other people living at the home at risk of harm.

People told us they didn’t always feel safe and protected from avoidable harm. One person described staff supporting them with personal care by using a hoist. However instead of supporting them to a wheelchair to then be taken to the bathroom they were moved through corridors of the home in the hoist. The person said, “It was awful, I dislike the hoist at the best of times, this just left me feeling dizzy and sick for hours as I was swinging backwards and forwards like crazy.” Another person said, “I don’t feel safe living here at times, recently there was another resident here, shouting and smashing things and I was made to go and sit in my room for hours.”

The staff and management team were knowledgeable about safeguarding, had untaken relevant training and the provider had a current policy in place to support staff. However, staff told us they did not get feedback or updates from safeguarding concerns they had raised. Some staff told us they had reported their concerns directly to the local authority and the Care Quality Commission to ensure information was shared to protect people when they had not received updates, or their concerns remained.

We observed a staff member supporting someone to reposition in a chair by placing their hands on their knees and pushing the person backwards. This is not an acceptable manual handling technique and placed the person at risk of harm, pain and injury. We alerted the management team immediately who took steps to ensure the person’s safety and welfare.

We reviewed the provider’s quality monitoring records for safeguarding concerns. We identified several events such as falls and incidents of aggression between people living at the home that had not been reported to the local authority, were not recorded in the provider’s own system nor notified to the Care Quality Commission in line with legal requirements. We spoke with the manager who acknowledged they were not aware these had not been completed and stated they would ensure this was rectified and monitored going forward.

People were not supported to manage risks safely. People told us they had reported concerns to management and no action had been taken. For example, one person said, “I was approached by another resident who was aggressive and tried to hit me, this person is still left unsupervised in the lounge with us. I’m so frightened all the time.” Another person told us, “I need my walker to get about, but as soon as I sit down staff move it and then I can’t get back up again when I need to, I can do it myself, but I have to wait for staff because of this.”

Staff were not knowledgeable about people’s identified risks or appropriate use of restraint. The compliance manager spoke with a member of staff who was seen pulling a person by the arm. The staff member stated to the compliance manager, “Sometimes it’s just quicker.”

We observed several staff members using inappropriate manual handling and restraint techniques. For example, staff grabbed people by the wrist and pulled them in their chosen direction rather than supporting people in a person-centred way or as identified within their plan. We also observed 2 staff members drag lifting a person from a wheelchair. This involves a method of lift where a person is pulled/dragged up from under their arms which places them at risk of harm. We conducted a short follow up visit to observe the immediate changes the provider and management team had put in place following our assessment. We observed safe manual handling practices during this visit and confirmation that staff had received competency checks in this area to ensure people’s safety.

Processes and care plans in place did not always accurately identify risks to people or reflect how people wished to be supported. For example, one person’s care plan stated due to past trauma they experienced anxiety if supported or left alone with male staff. We observed, and records showed, this person was consistently supported by male staff and at times there were no female staff within the home. Another person had been identified at risk of being overweight and had a high BMI recorded. Their care plan reflected how they should be supported to lose weight. However, the risk assessment had been completed incorrectly and the person’s BMI was bordering on them being underweight. This meant the person was receiving incorrectly assessed care which placed them at risk of harm.

People did not always experience a safe environment. For example, a person left the home for a day out with family. During the day staff were seen actively looking for this person and were not aware that they were not currently in the home until informed by the assessment team. This meant that in the event of an emergency staff were not clear on how many people needed to be accounted for and supported.

We spoke with management about concerns we observed on assessment regarding the safety of the environment. Although management took immediate action to ensure people’s safety, they were not aware of the concerns prior to our feedback.

We observed a member of the maintenance team undertaking repair work to the dining room ceiling following damage from a leaking pipe. This work involved power tools and exposed people to dust and debris. As this work was being completed there was a person sat eating at a table in the vicinity and staff were assisting people to the dining room ready for lunch and people, some of whom were living with dementia, were left unsupervised to wander in this area. We asked the compliance manager whether the repair works to the dining room ceiling being completed had been risk assessed to keep people safe and they confirmed they had not been. This placed people at risk of harm.

The provider had risk assessment and management policies in place, such as quality audit and daily walk rounds, however these were not used effectively to identify, action or mitigate incidents we saw on assessment which meant people had been placed at risk of avoidable harm.

People told us they did not feel safe with the staffing levels within the home. People described situations where they needed to shout and bang objects on tables to gain staff attention whilst in communal lounges. One person said, “We raise this issue all the time and have been told there will always be a staff member in the lounge, but it doesn’t happen. I bang my coffee cup on the table to make enough noise to be heard.” Another person said, “It’s just not safe, from about 6pm staff disappear. I have had to wait over an hour to get help going to the toilet.”

Staff we spoke with told us changes made since our last assessment had not been effective and this had impacted staff productivity and availability to support people. One staff member said, “Some days I’d be rostered to be in the kitchen but I’m a care assistant, I don’t want to work in the kitchen I find it very stressful.” Another staff member said, “It’s virtually impossible to get any annual leave, the manager told me to say I have an emergency to get leave but it still wasn’t approved. This means people go off sick and this creates further problems for staff and residents we support.”

Our observations supported the feedback about people’s experience. Communal areas were left unsupervised for large periods of time and people did not have a method of alerting staff for any issues or care needs.

The management team acknowledged the issues we raised and took immediate action to improve staff availability. However, there was no evidence that recent competency checks had been undertaken to support staff with areas for improvement or to provide feedback on performance in areas such as manual handling and restrictive practices. This meant the management team did not have oversight of how effective staff were at keeping people safe.

People were not protected from the risk of harm from infection prevention and control practices within the home. We observed people being served food from a kitchen that did not meet specified industry hygiene standards and placed people at risk of harm from cross contamination. However, people did tell us they were happy with the level of support they received regarding the cleaning standards generally within the home. One person said, “The [domestic] staff are always busy cleaning, they don’t stop.”

We spoke with members of the kitchen staff who told us that due to role changes made by the provider there were not enough staff to ensure cleaning within the kitchen could be completed daily. One staff member said, “There used to be three of us in the kitchen daily but changes mean there is only one now, it’s impossible to cook, serve, prepare food and clean everywhere.”

During the assessment we noticed a strong urine odour on the first floor of the home. We checked people’s bedrooms in this area and found a bedroom, which had been documented as being cleaned by housekeeping, to have urine-soaked bedding and pillows. Corridors within this area also emitted the same odour and were sticky. We completed further bedroom checks and found multiple rooms with stained bedding. We raised this with the management team who acted immediately to address the concerns.

Quality monitoring processes did not identify the issues we found on inspection. For example, cleaning records for the kitchen had not been completed consistently for over a month, however management had failed to identify or action these concerns. This meant that people had been placed at ongoing avoidable risk of harm from poor infection prevention and control.

People did not receive their medicines safely or in line with best practice guidance. For example, we observed a person being given their medicine covertly by staff placing it in food and then supporting them to eat it. The staff member was not trained in administering medicines and this person did not have a covert medicine plan in place. This placed the person at significant risk of harm. We raised this concern with the compliance manager who acted immediately to ensure people’s safety.

We observed medical waste equipment such as sharps boxes, which are used to dispose of used needles, being stored in communal lounges where people, some of whom were living with dementia had unsupervised access to. We spoke with staff about this, and they told us it was done for the ease of other visiting professionals such as district nurses. We spoke with the manager about this who acknowledged this was not good practice and immediately arranged the removal of the items.

While audits were being completed, they did not identify the issues we saw on the assessment. For example, medicines trolleys were stored in communal lounges and were not secured to the wall when they were not in use. This was not best practice. This practice was observed on all 4 separate assessment visits to the home. The medicine room was clean and stocked appropriately with weekly stock checks being completed. Medicine administration records were reviewed, and these were completed appropriately and reflected stock levels we saw on the day. Where people required support with ‘as needed’ medicines there was clear guidance for staff within people’s care plans.