Stoneyford Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Despite improvements throughout the service and improved quality monitoring processes since our last assessment, errors and gaps in recording of information throughout the home in all aspects of care remained. Where audits had identified errors and the management team had been alerted to follow up action, records and documents did not show that those required actions had been undertaken. Overall people and staff told us there had been a change in the culture of the home. People and staff told us they were encouraged raise to concerns and provide feedback.

The provider was in continued breach of legal regulation in relation to the governance of the service.

This service scored 54 (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 shared vision, strategy and culture. There was a service improvement plan in place to track developments and ensure the required measures were taken to maintain and improve the service to a safe standard. The management team all had responsibility for ensuring these actions were completed. Improvements had focused on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. People and staff told us there was no longer a fear culture at the home. Minutes from team meetings and staff feedback questionnaires showed this area was regularly discussed and reviewed and people and relatives were also encouraged to share their opinions with similar methods.

The service has experienced changes in the management team, but the current home manager and compliance manager were open and honest about previous issues with the inspection team and had driven improvements in the service which people and staff supported and told us had taken place. Staff told us the manager was compassionate and supported them. One staff member said, “[Manager] is really approachable, I get a lot of support whenever I need it.” However, records did not always reflect actions taken or support offered to people and information repeatedly appeared copied and pasted from previous reports and did not fully list actions undertaken. The inspector spoke with the compliance manager and the provider about support for the manager to further develop in their new role and build on the skills they needed to effectively lead the team and focus on how they could enable people to live safely and were supported with care that promoted positive outcomes.

People, their relatives and staff told us they were encouraged and supported to speak up. Everyone we spoke with told us they knew how to raise a complaint and would be confident to do so. One relative we spoke with said, “I raised a complaint and the issues seemed to be dealt with but there was no apology or follow up information given.”

The management gave assurances that complaints were investigated but this was not effectively documented or in line with the provider’s policy. There was a copy of the home’s complaints policy available for people in an accessible format.

The provider supported improvements to workforce equality, diversity and inclusion. We did not find any evidence of issues about the fair and equitable treatment of staff and staff we spoke with did not highlight any concerns about this. The provider had taken feedback from staff at the last inspection about roles and responsibilities and ensured staff worked in areas and undertook tasks and care delivery they were trained in. However, some people and their relatives raised ongoing concerns about language barriers between them and staff and whilst all said improvements had been made at times it was still an issue. We could not find any record of the concerns surrounding this risk despite the manager acknowledging the ongoing issue and describing their continued support in staff development in this area.

The provider has implemented quality monitoring process in the home since the last assessment that were supported by daily and weekly audits from the provider’s head office staff team. The aim of the team was to review records and identify gaps or where follow up actions were needed. This process had limited success as although it had highlighted some gaps we found on the inspection, the management team could not evidence they had followed up or acted on the audit findings. For example, the team had identified a person needed further welfare checks after having a lower body temperature recorded and had emailed the manager to request this. However, there was no evidence these additional checks had taken place or that staff had mitigated the risk via any other method. The provider responded to this feedback and implemented an immediate action plan to upskill staff in identifying and responding to audit action points to ensure people were kept safe.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff did not always document actions and care delivered in line with guidance and feedback from partners. Management reviews and audits had not identified the gaps in recording keeping prior to concerns being raised on inspection. This meant the management team lacked oversight of the risks relating to missed care delivery and support which placed people at risk of harm. Professionals who worked with the service raised concerns that the management team had not identified and planned effective and responsive care for people with risks of pressure damage. However, the management team were actively working on improving this area of care at the time of our inspection and had mitigated risks to keep people safe during this process.

The provider did not always focus on continuous learning, innovation and improvement and encourage creative ways of delivering equality of experience, outcome and quality of life for people.

At the inspection carried out in July 2024 it was identified that quality assurance processes were not in place which was a breach of Regulation 17 Good Governance. The provider and management team had failed to fully learn from this process, despite significant improvements in relation to the quality of person-centred care. Improvements in ways of working, specifically in relation to record keeping and quality assurance processes relating to this that assured risks were identified, monitored and acted upon, had not been implemented and improvements had not been made. The provider remained in breach of this regulation.