20 January 2022
During an inspection looking at part of 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.