Stoneacre Lodge Residential 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 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Accidents and incidents were logged and recorded but analysis of the information was simplistic. It did not identify themes or trends to improve the quality of care and support to keep people safe.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. People had not always received timely referrals to clinical support services such as speech and language therapists and dieticians when concerns were identified about weight loss.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. There was a safeguarding log in place where concerns and outcomes were recorded but it was incomplete and not up to date. There was no evidence of how safeguarding incidents were analysed to identify lessons learned. There were no mechanisms which demonstrated how learning was shared with staff to make changes and improvements to the service.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks were not identified or mitigated in people’s care plans. Care plans were not reviewed in a timely manner and this meant care was not delivered in line with people’s identified needs. This put people at risk of harm. This is a breach of regulation 12 safe care and treatment and we asked the provider to take action.

The service did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. Radiators covers were not in place for some radiators in the care environment. These radiators were hot to the touch and were a risk to people living in the care home. Records of water temperatures and cleaning and descaling of showers were not completed or recorded and there was no management oversight of these records. This put people at risk of harm. This is a breach of regulation 12 safe care and treatment and we asked the provider to take action.

The service made sure there were enough qualified and skilled staff who received effective support, supervision and development. Staff were recruited safely and a range of checks including references and disclosure and barring checks (DBS) had been requested and obtained prior to new staff starting work in the service. Staff were caring and compassionate in their support for people. When we asked people about the staff, a family member told us, “They are always very polite and seem very friendly people.”

The service 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. We saw evidence of full clinical waste bags left open on a toilet floor which were full of used continence products. This caused an infection control risk and an unpleasant odour. People told us staff used personal protective equipment (PPE) appropriately, “PPE is always used when sickness is around. [There are] no restrictions of visiting only that they ask we try not to come at lunchtimes.”

The service did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were not managed safely. Administration of controlled drugs was not signed by 2 people and body maps for the administration of pain patches were not used effectively. This put people at risk of harm. This is a breach of regulation 12 safe care and treatment and we asked the provider to take action.