CQC report explained · a residential care home
What the CQC found at Stainsbridge House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2019
Rated Requires Improvement; inspectors saw kind, responsive care, but found gaps in risk assessments, medicines guidance and management checks.
Inspectors visited without prior notice on 2 and 3 April 2019. They spoke with 15 people, six relatives, 12 care staff and managers. They observed care and checked records, medicines, recruitment, training and how the home was managed.
People generally described kind care and said they felt safe. Inspectors found enough staff, good support with food and healthcare, meaningful activities and respectful interactions. The home had improved since the previous inspection, including its care plans, medicines systems and quality monitoring.
The overall rating was Requires Improvement. Safe and Well-led were Requires Improvement, while Effective, Caring and Responsive were Good. Inspectors still found risks that had not been fully assessed, missing guidance for some medicines given when needed, one incomplete enhanced background check and weaknesses in monitoring and records.
Kind and respectful care
Inspectors saw staff interacting meaningfully with people and supporting their dignity, choices and independence. Relatives gave many positive comments about staff kindness.
“There were many positive comments about the kindness and caring nature of the staff.” from the report
Enough staff
During the inspection, staffing levels appeared sufficient to meet people's needs. Call bells were answered promptly and care needs appeared to be met.
“Observations over the two days indicated that there were enough staff to meet people's needs.” from the report
Food and nutrition
People could choose what to eat and were supported without being rushed. Staff adapted food and drinks to people's needs.
“People told us they liked the food and were able to make choices about what they had to eat.” from the report
Personalised activities
The home offered activities such as cooking, music, movement and one-to-one time. Staff used people's hobbies and interests to plan engagement.
“An activity programme was in place providing opportunities for people to participate in a variety of events.” from the report
Improved care planning
Care plans were clearer and contained more information about people's individual needs and preferences than at the previous inspection.
“At this inspection we saw that action had been taken to meet this regulation.” from the report
Incomplete risk assessments
seriousSome risks were not properly assessed or reflected in care plans. This included choking, smoking and behaviour that could be verbally or physically challenging.
“Risks identified had not always been assessed. This included incidents of behaviour that could be verbally or physically challenging.” from the report
Missing medicines guidance
needs fixingFive medicine records reviewed did not have protocols for medicines prescribed to be given when needed. This could leave staff without clear guidance.
“There were missing protocols on five of the MAR 's reviewed.” from the report
Incomplete recruitment check
needs fixingOne staff member had started work without an enhanced Disclosure and Barring Service check. The provider applied for one during the inspection and stopped the person administering care until it was received.
“We saw one staff member did not have an enhanced DBS check completed.” from the report
Weak quality monitoring
needs fixingSome audits did not check enough detail and one risk assessment audit failed to identify missing risk assessments. There was also no working action plan for the home manager.
“The system for monitoring the quality of the service had improved. However, some areas of the audits needed to include further details of what needed to be checked.” from the report
Cleaning and laundry concerns
minorSome relatives raised concerns about smells, cleanliness and missing laundry. Inspectors also saw a staff member move to other areas without removing gloves after personal care.
“One relative said "I worry about the cleanliness. It could do with a deep clean, the bedroom floor is sometimes sticky, and bins are dirty.” from the report
- 01What has been done to assess and manage risks linked to behaviour that can be verbally or physically challenging?
- 02Do all medicines prescribed to be given when needed now have clear, individual protocols?
- 03Has the enhanced Disclosure and Barring Service check been completed for the staff member mentioned in the report?
- 04How do you now check that risk assessments, medicine records and audit findings are complete and accurate?
- 05How are laundry problems, cleaning concerns and communication with relatives being monitored and addressed?
This was a planned inspection of the whole care home, covering the premises and care provided and assessing all five CQC questions. This explanation was written from the published report of 21 June 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2018
Rated Requires Improvement; inspectors found kind care and good activities, but medicines, risk records and management systems were not always safe or reliable.
This was an unannounced inspection on 4 and 5 June 2018. Inspectors spoke with people living in the home, relatives, staff and health professionals. They reviewed care records, medicine records, staffing and recruitment records, and watched care being provided.
The home was caring, clean and homely. People said staff were kind and knew them well. They also spoke positively about the food, activities and opportunities to follow their interests.
However, medicines and risk management were not always safe. Records about food, drinks, repositioning and incidents were incomplete or unclear. The home also did not always follow the correct legal process when people could not consent to care or restrictions.
The overall rating was Requires Improvement. Safe, Effective, Responsive and Well-led were all rated Requires Improvement, while Caring was rated Good. The home had met the staffing breach found at the previous inspection, but this was the second consecutive Requires Improvement rating and CQC was considering further action.
Kind and respectful care
People appeared comfortable with staff, who knew their preferences and responded sensitively when they became anxious. Relatives were positive about the care.
“Staff demonstrated that they knew people well and supported people accordingly.” from the report
Activities and interests
People were encouraged to join activities and continue interests such as gardening and helping with daily tasks. Activities were available seven days a week.
“People were encouraged to follow previous interests and participate in daily life at Stainsbridge.” from the report
Food and choice
People said they enjoyed the food and had choices and alternatives. They could choose where to eat and were offered drinks during the day.
“People said they liked the food because they had a good choice and alternatives were available if they wanted something different.” from the report
Recruitment checks
The home completed checks before employing new staff to make sure they were suitable and of good character.
“Safe recruitment practices were followed before new staff were employed to work with people.” from the report
Clean environment
Inspectors found the home clean and homely. Cleaning schedules and equipment were in place to reduce infection risks.
“We found the service to be clean and homely.” from the report
Medicine safety
seriousGuidance and records for fluid thickeners were unclear, and it was not clear whether one person had received the correct thickener. Inspectors also found gaps in medicine records and fridge temperature records.
“Medicines were not always managed safely.” from the report
Unmanaged risks and incidents
seriousSome risks, including choking, falls and pressure damage, did not have clear instructions. Injuries and falls were not always fully recorded or monitored.
“The risks to this person had not been effectively managed.” from the report
Consent and restrictions
seriousThe home did not always complete capacity assessments or best-interest decisions before using restrictions such as sensor mats, bedrails or controlled access to the lift.
“This meant that people had been restricted without the appropriate legal processes being followed.” from the report
Incomplete care and monitoring records
seriousCare plans lacked detail, and records of food, drinks and repositioning had gaps. This made it difficult to know whether people's needs had been met.
“This meant the monitoring charts were ineffective to support the risks identified to people.” from the report
Weak management checks
needs fixingAudits had identified some problems, but action was not always recorded or taken promptly. The provider had not had enough oversight of the day-to-day running of the home.
“Although we saw that similar findings to our inspection had been identified, the actions to follow up were not always recorded or taken in a timely manner.” from the report
Staffing pressure
needs fixingThe previous staffing breach had been met, but staff said levels could be better. Inspectors saw three people in nightwear at 5:30pm, which staff attributed to staff shortages.
“We observed on the first day of inspection that three people were walking around at 5:30pm in their night wear.” from the report
- 01How have you made sure people receive the correct prescribed fluid thickener, with clear guidance from the relevant health professionals?
- 02What has changed in care plans and daily records for choking, falls, nutrition, fluids and repositioning?
- 03How do you now complete and record mental capacity assessments and best-interest decisions before using bedrails, sensor mats or lift restrictions?
- 04Who is the registered manager now, and how is the acting manager being supported?
- 05How do your current audits identify problems and prove that they have been fixed?
This was an unannounced comprehensive inspection covering all five key questions and the overall rating. This explanation was written from the published report of 15 August 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Stainsbridge House
4 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- June 2019Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 4 February 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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