CQC report explained · a residential care home
What the CQC found at Stamford House Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2023
Stamford House Care Home was rated Good; inspectors found improved, kind care, but some recruitment, care-record and oversight work remained.
This was an unannounced follow-up inspection on 25 and 26 January 2023. Inspectors spoke with four people, two visiting professionals and six staff. They visited both floors and checked care, medicines, staff recruitment and management records.
The overall rating was Good. All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that staffing, medicines, risk assessments, activities, care planning and management oversight had improved since the previous inspection.
Some work was still needed. Inspectors found historic gaps in two employment records, minor gaps in care records and a need for stronger senior oversight of audits. They made recommendations, but found no current breaches of regulations.
Safer medicines
Medicines were stored securely, staff were trained and records accurately showed what people should receive.
“Medicines were stored safely and securely. There was an accurate record of people's medicines in the home to help make sure medicines were given safely.” from the report
Kind and respectful care
Inspectors saw caring interactions. People said staff treated them well and respected their dignity.
“People were treated well, and their dignity was being respected.” from the report
Improved activities
The new activities coordinator was helping people take part in more activities and plan community and outdoor activities.
“An activities coordinator had recently been recruited.” from the report
Food and dietary support
Food was stored and checked appropriately. Inspectors saw people's dietary needs and wishes being followed.
“People were supported to maintain a balanced diet.” from the report
Positive culture
Staff and people gave positive feedback about management and the changes made since the previous inspection.
“The registered managers promoted a positive open culture.” from the report
Recruitment records
needs fixingBoth recruitment files checked had historic gaps in employment that had not been followed up. Inspectors recommended reviewing recruitment processes.
“Both recruitment files viewed had historic gaps in employment which had not been addressed.” from the report
Care records still need detail
needs fixingCare plans had improved substantially, but some daily notes, health-specific plans and risk assessments did not yet contain all the detail needed.
“We noted significant improvements in care records, however there were still some minor pieces of work to do to ensure daily notes and health specific care plans and risk assessments were as detailed as they should be.” from the report
Senior oversight
needs fixingAudits were stronger, but the provider needed to show better oversight of management audits. Inspectors made a recommendation about governance.
“However, provider oversight needed to be increased to demonstrate appropriate oversight of management audits were taking place.” from the report
Dementia-friendly environment
minorSome adaptations and signage were in place, but further work was needed to make the home more suitable for people living with dementia.
“Further work could be made to make the home more dementia friendly, the registered manager was in the process of making these improvements.” from the report
- 01What action has been taken to address the historic gaps in employment records?
- 02How are care plans, daily notes and health-specific risk assessments checked and updated?
- 03How does senior management now oversee the home's audits and make sure recommendations are completed?
- 04What further changes are planned to make the home more dementia friendly?
- 05How will activities be tailored to each person's interests, including access to the garden and community?
This was an unannounced follow-up inspection covering all five CQC questions, including infection prevention and control, after the previous Requires Improvement rating. This explanation was written from the published report of 24 February 2023 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, November 2022
Rated Requires Improvement; medicines, care records and management systems were not reliable, although caring improved to Good and the home left special measures.
This was an unannounced follow-up inspection after the home was previously rated Inadequate. Inspectors visited on 12 and 13 October 2022, gave feedback remotely on 20 October, spoke with people, a relative, staff and a health professional, and checked care, medicines, staffing and management records.
The home had improved in several areas. People said they felt safe and were treated kindly and with dignity. Infection control was safe, staff training levels were high, people received support with food and healthcare, and safeguarding systems had improved.
Important problems remained. Medicines were not always managed safely. Care plans did not always contain accurate or complete information about people's needs and risks. Activities were not regular, staffing was sometimes low, and audits had not found all the problems. The home remained in breach of regulations about person-centred care, medicines and governance.
The overall rating changed from Inadequate to Requires Improvement. The home was no longer rated Inadequate in any key question and was no longer in special measures, but CQC said it would continue to monitor the service.
Kind and respectful care
People were treated well and their privacy and dignity were respected. Families and people spoke positively about staff.
“People and their families spoke positively about staff.” from the report
Improved infection control
Inspectors were assured that infection risks were being managed, including the safe use of protective equipment and support for visitors.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staff training and support
Staff received induction, supervision, appraisals and training. Training compliance was high.
“Various training courses were available for staff to provide them with the skills and knowledge required to meet people's needs and training compliance rates were high.” from the report
Food and healthcare support
People's dietary requirements were followed and staff supported people to access healthcare when needed.
“People were supported to maintain a balanced diet.” from the report
Medicines safety
seriousMedicines were not always secure or accurately recorded. Some staff did not have enough information about when-required medicines, and night-time access to medicines could be delayed.
“Systems were either not in place, not being followed or not robust enough to demonstrate medicines safety was effectively managed.” from the report
Incomplete care planning
seriousSome care plans lacked important assessments or contained information that was out of date or contradictory. This meant staff might not have had the information needed to meet people's needs safely.
“The provider had failed to ensure staff provided people with individualised care which met their needs.” from the report
Limited activities
needs fixingThere was no activities coordinator working at the time of the inspection and people said there were no regular activities. The home was asked to ensure people were engaged in meaningful activities.
“People's comments included, "They don't do any activities in the home it can be boring” from the report
Staffing levels
needs fixingSome shifts were below the level suggested by the home's dependency tool. Staff said having fewer people on duty was a struggle, although inspectors found no impact on people at the time.
“Rotas showed that some shifts were under-staffed based on the dependency tool used to calculate people's dependency.” from the report
Weak oversight
seriousAudits had not identified all the risks found by inspectors. Provider oversight and analysis of survey results needed to improve.
“The provider had failed to ensure good governance.” from the report
- 01What has been done to make sure medicines are stored securely and recorded accurately, including when-required medicines?
- 02How do you make sure a staff member can administer medicines during the night if someone needs them?
- 03Have all care plans and risk assessments been reviewed and updated, including falls, skin care, continence and health conditions?
- 04How many staff are usually on duty on each shift, and what happens when staff are absent?
- 05What regular meaningful activities are now available, and who is responsible for organising them?
This was an unannounced follow-up inspection after the previous Inadequate rating, covering all five key questions and infection prevention and control, with feedback given remotely on 20 October 2022. This explanation was written from the published report of 19 November 2022 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.
Every inspection of Stamford House Care Home
7 rated inspections over 8 years: the service has held its Good rating throughout.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2022Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2022Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2022InadequateSafe: InadequateWell-led: Inadequate
- November 2020Inspected but not ratedSafe: Inspected but not rated
- September 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- June 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- October 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 1 December 2010.
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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