Stonedale Lodge 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

People did not always receive safe care and treatment. Accidents and incidents were not shared with relevant others including family members. Accident and incident records lacked information about the action taken to prevent further occurrences and lessons learnt from the events. Safeguarding procedures were not always followed to protect people from the risk of harm and abuse. Managers and staff failed to recognise and report potential safeguarding concerns onto the relevant agency for investigation. Safeguarding records lacked information about the immediate action taken to keep people safe. Equipment was not always suitable and used safely for people. Medication was not always stored, recorded or administered safely. Staff failed to respond to call bells for people who occupied their bedrooms and were experiencing pain and discomfort. Staff felt rushed and under pressure. Advice was not always sought from external healthcare professionals, including for 2 people who were showing symptoms of a potential eye infection. Garden areas people accessed were unsafe and unclean. There were tall weeds growing on pathways, broken garden furniture which was unsafe and used items of used PPE scattered around. Communal living spaces, bedrooms, laundry and kitchen/s were overall clean and hygienic and there was a good stock of PPE and bins available across these areas.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some family members told us they were not told about incidents that effected the health and safety of their relatives. One family member told us staff had not shared the full details of an incident which resulted in their relative being hospitalised. They said full details were shared by hospital staff. Another family member told us they had not been informed about an injury their relative sustained.

Staff told us they were aware of the providers accident and incident policy and procedure. A member of staff told us, “I know there is one, not seen it for a while.” Another member of staff told us we don’t always have time to read stuff like that. Staff explained what they would do in the event of an accident or incident, a member of staff said, “I’d report to a manager and fill in a form.” Staff were unsure of any formal process for the sharing of information and learning following accidents and incidents. A member of staff told us, “We usually talk about things that have happened at handover meetings.”

The provider had policies and procedures in place for managing complaints and events such as accidents, incidents and safeguarding concerns. However, systems and processes did not assure us they operated a proactive and positive culture of safety. Safeguarding procedures were not always followed to protect people from further risk of abuse. Accident and incident records lacked details about each event which occurred and there was no evidence to show the events had been analysed to help identify any themes or trends and ways to mitigate the risk of further occurrences. There was no evidence to show learning had taken place and shared with staff following events that impacted on people’s safety. We did not receive the complaints records we requested; therefore, we were unable to assess the effectiveness of the providers processes for managing complaints and what lessons were learnt from them.

Family members did not always feel they were consulted about future plans to move their relative onto other services. A family member told us they were not informed about the plans and timescales in place to move their relative to another service. Another family member told us they had expressed concerns to management they did not receive the providers letter or email informing them about the plans to close the unit and had to find out via the Local Authority.

Staff told us they understood their responsibilities for ensuring safe systems of care including working with other professionals and services, to help ensure people received continuity of care. Staff told us they were confident in recognising and responding to any changes in people’s needs. One staff member told us, “The service works well with other professionals, we have district nurses that come in.” However, we found examples where staff had failed to escalate concerns about people’s health, safety and wellbeing to other partners.

Partner agencies shared concerns with us about people’s safety.For example, during the month of October 2024 prior to our assessment site visit the local authority safeguarding team shared concerns about poor wound care for 1 person and unsafe management of medication for 3 people.

We were not assured safety was managed and monitored. Records were not always completed each day as required to ensure the safety of equipment used by people to keep them safe from harm. This included checks on airflow mattress settings for people at risk of skin breakdown and bedrail checks for people at risk of falls. We found bedrail protectors incorrectly fitted for multiple people placing them at risk of injury.

People told us they felt safe and were treated well. Their comments included, “I feel safe here” and “It’s ok here.” However, family members told us they did not always feel their relative was kept safe. A family member told us, “We don’t overall feel that [relative] is safe here.” Another family member told us, “Sometimes the staff are too busy, I come every day, so I know that [relative] is safe.”

Staff and managers told us they had completed safeguarding training and were confident about recognising and raising any concerns they had about people’s safety. However, we identified examples where staff had failed to recognise and report potential safeguarding concerns placing people at risk of further abuse.

We observed staff communicating well with people. However, we observed examples where staff failed to identify and act upon potential safeguarding concerns which placed people at risk of harm. For example, we observed 2 people with watering eyes which staff had not escalated onto external healthcare professionals for medical advice. We observed unsafe equipment in use which staff failed to recognise and act upon.

The providers systems and processes did not always protect people from the risk of abuse. Safeguarding records did not provide details of the immediate action taken to protect people from the risk of further abuse. There were missed opportunities to respond to people at risk of harm. Concerns around the management of people’s finances and personal belongings were identified through the providers governance systems and processes, however, this was not investigated by the provider or referred onto other relevant agencies for investigation.

Family members told us they were not always involved in the management and reviewing of risks in relation to their relative. They told us they did not always feel risk was safely managed. A family member told us their relative was at risk because they did not have the correct mattress, they said they had raised their concerns with managers on a number of occasions, but nothing had changed. Another family member told us they were concerned about the security of their relatives’ personal belongings, but nothing had been done despite them raising their concerns multiple times.

Managers told us they reviewed risk regularly involving people and relevant others such as family members. Staff told us they were kept up to date with current and changing risks through shift handovers and care plans. However, we observed instances where staff and mangers failed to recognise and respond to risk.

Risks to people were not always properly mitigated and managed exposing them to the risk of harm. We observed examples where people had not received daily hair, nail and skin care in line with their care plan exposing them to risk of harm. We observed an unlocked medicines box in a person’s bedroom which contained prescribed creams. The box was on top of the person’s bedside cabinet accessible to other people, some of whom were living with dementia. We observed examples where people did not have the right equipment to keep them safe and multiple examples where equipment in use was not used safely in line with the person’s risk management plan. For example, one person did not have the correct mattress placing them at risk of harm and 7 people were placed at risk of harm from their bedrails because their bedrail protectors were incorrectly fitted. When visiting people in their bedroom’s inspectors activated call bells for 2 people who required staff assistance. Staff failed to respond to both call bells, and they were turned off from the monitor in the lounge area.

Although risk assessments were completed for people, there was no evidence from people's care records they or their representative had been directly involved in the process. Where risk had been identified, appropriate action to minimise risks was not always followed in line with people’s care plans. For example, a person at risk of skin breakdown was not always repositioned in line with their care plan. Another person’s daily hygiene records were completed to show they had received nail and skin care to avoid harm, pain and discomfort, however, our observations showed the person had not received this care.

People told us they felt safe in their environment. Family members told us they did not always sign in the visitor’s book on entering the unit. A family member told us, “I don’t always sign in, it depends which staff let you in, some ask you to sign in some don’t.” Another family member told us, “I’ve signed in today but not always.” Family members told us they thought overall the environment was safe, however, one family member raised concerns about the safety of equipment used by their relative and another family member raised concerns about the security of their relatives’ bedroom and personal belongings.

Feedback from staff and leaders confirmed they had completed training in topics of health and safety. Staff told us they understood their responsibilities for ensuring a safe environment and the safe use of equipment. Staff told us they had received fire safety training and would feel confident in knowing what to do in an emergency. One member of staff told us, “I’ve had fire drills, and I feel confident.”

Inside areas of the home were safe and free from hazards. However, we observed hazards in garden areas accessible to people. There were large weeds growing in between pathways presenting a trip hazard and there were items of broken garden furniture which were unsafe for use. We observed bedrail protectors incorrectly fitted for multiple people who were being nursed in bed, placing them at risk of harm. We immediately raised this with a senior member of staff who carried out a full check on all bedrail protectors in use and made them safe.

Records showed safety checks were completed at the required intervals on utilities and appliances such as gas, electricity, fire alarms and fire equipment. However, daily records were not always completed to show the required safety checks had taken place on equipment used by people. This included checks on bedrails and protectors and air flow mattress settings.

Family members told us they did not feel there were enough staff to keep their relative safe. Their comments included, “Staff often look stressed and at times there does not seem to be enough around particularly permanent nursing staff, they always use agency” and “Staff turnover is very high and not always sure who is in charge of the unit on any given day.” A family member commented they felt due to shortage of staff and it being very busy their relative had not received the care they needed which resulted in them sustaining an injury.

Feedback from staff was mixed as to whether there were enough of them on duty to support people safely. Staff told us it was harder when regular members of staff called in sick. Staff explained that although managers would always fill in any gaps in the rota with agency, it wasn't the same as having a team of regular staff who were familiar with people’s care and support needs. One member of staff told us, “We are ok, and we can get busy, we could do with more, it all depends on activities, and if we have lots of visitors, as that can take up our time.” Staff told us they had undergone all the necessary checks before starting at the service and had received an induction which they felt had prepared them well for the role. One member of staff told us, “When I started, I had 2 days induction and assigned a staff member to shadow. I had my online training and had to complete a training booklet. It was useful.” Staff told us they didn't always receive support via supervision or appraisal. One member of staff commented, “We don't always have it (supervision and appraisal), but the manager does check we are OK.” The manager acknowledged they were behind with staff supervisions and appraisals and had a plan in place to bring them up to date.

We observed some people being cared for in bed were left for long periods of time in their rooms without any staff presence to ensure their safety and wellbeing. We found it difficult to locate staff and they were not always visible in communal areas people occupied as they were busy engaged with other tasks such as attending to people’s personal care needs.

Staffing numbers and skill mix for each of the units were calculated based on people’s needs and occupancy levels. However, the staffing rotas reviewed did not always accurately reflect the actual staff on duty or the right amount of suitably skilled staff required to safely meet people’s needs. For example, qualified nurses and the service manager working during our site visit were not named on the staffing rota and we saw examples where there were no qualified nurses named on the rota in areas where they were required.

People and family members told us bedrooms, bathrooms and communal areas were kept clean and hygienic and staff used PPE for tasks such as when providing personal care and handling food. People’s comments included, “They wear aprons when they do things. I think it’s clean” and “Yes kept clean (bedroom).” A family member told us, “I see staff wearing aprons and gloves.”

Staff confirmed they had completed infection prevention and control (IPC) and PPE training and had access to IPC guidance. They explained safe IPC practices including the use of PPE and disposal of waste. Staff told us they had access to PPE. Their comments included, “I’ve had IPC training” and “I’ve been observed donning and doffing.”

Practices observed were not always safe increasing the risk of the spread of infection. We observed inside areas of the home and equipment to be clean and hygienic, and a good stock of PPE available which staff used safely. However, we observed lots of cigarette butts on pathways and in borders and dirty garden furniture in gardens accessible to people. We observed items of used PPE and incontinence aids scattered around a garden people accessed.

Whilst there were processes in place for managing the risk of infection, they were not always used effectively to bring about improvement. Cleaning schedules were in place for people’s living environment, equipment, the kitchen and laundry. The kitchen recently achieved the maximum award from a recognised external agency for high standards of cleanliness and hygiene. Monthly IPC audits reviewed identified areas for improvement across the units and actions and timescales for completion were set. The audits showed actions had not always been completed within the timescales and remained pending past the date for completion. Infection outbreaks were safely managed in line with guidance set out by the community infection, prevention and control team.

Records showed some people had not been given their prescribed medicine as there was no stock available to administer them, placing their health and wellbeing at risk. When people were prescribed medicines to be given at specific times, records showed they were not always given at the correct time. There was a risk the condition the medicine was given to treat would not be controlled which might have affected their quality of life. We found medicines to be given before or after food were not given following the manufacturer’s instructions so there was a risk they might not work properly. When people were prescribed topical preparations, for example medicine patches. The records showed they were not always applied following the manufacturer’s instructions so there was a risk people might have experienced unnecessary side effects. The application of creams was not always recorded so we could not be sure they were being applied as prescribed.

The management team were not always aware of the medicines that were not available to administer to people. Audits were completed and showed improvements were needed; however, the actions were not always completed; some of the issues identified by the audits were also found during this assessment.

A medicines policy was in place; however, it was not always followed to ensure safe administration of medicines. Medicines with a shortened expiry once opened, did not always have the opening date recorded; there was a risk people might be given a medicine that had expired. Guidance between some people’s care records and their medicines administration records was inconsistent. Instructions were not always clear for administering medicines via a feeding tube, putting the person at risk of harm. Information to support staff to know when to give people their ‘when required’ medicines was not always person centred. In addition, when there was an option to give 1 or 2 tablets, there was not always information to guide staff on what dose to give. There was a risk people would not always get their medicines at the correct dose, when they needed them. Thickener prescribed to people to reduce the risk of them choking on food and drink, was not always recorded, therefore we were not assured the thickener was used placing them at risk of choking. Waste medicines were not always stored securely in line with national best practice guidance.