CQC report explained · a residential care home
What the CQC found at Standon House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were generally protected from abuse and received medicines safely, but environmental hazards, infection control practices and some medicine guidance needed improvement.
- Effective?
- Requires improvement
- This question was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Well-led?
- Requires improvement
- Managers were approachable and people were asked for their views, but quality checks did not consistently identify or correct known problems.
What inspectors found, October 2022
Rated Requires Improvement; inspectors found people were generally supported safely, but infection control, environmental safety and quality checks still needed work.
This was an unannounced focused inspection on 12 and 13 September 2022. Inspectors reviewed Safe and Well-led. They spoke with four people and seven staff, examined four care plans and checked records about medicines, training, health and safety, recruitment and the building.
People told inspectors they felt safe, received their regular medicines and could get help promptly. Staff were trained to give medicines, incidents were reviewed, and people were involved in day-to-day decisions. The home was also working within the principles of the Mental Capacity Act.
However, some equipment had rust, a corridor slope could cause trips and falls, and some staff wore nail polish or acrylic nails. There were also missing guidelines for some medicines and checks did not always find problems. The overall rating was Requires Improvement, as were Safe and Well-led.
Enough staff
People were supported by enough staff, and staff responded promptly when help was needed.
“People were supported by enough staff who were available to safely support them and who responded promptly when needed.” from the report
Medicine competence
Staff were trained and assessed as competent before giving medicines. Routine medicines were given when people needed them.
“Staff had been trained and assessed as competent to support people before administering medicines.” from the report
Learning from incidents
The management team reviewed accidents, incidents and near misses and considered whether extra support or professional advice was needed.
“The provider had systems in place to review any reported incidents, accidents or near misses.” from the report
People's involvement
People were involved in decisions about daily life, including activities, menus and room decoration.
“People told us they were involved in day to day decisions about where they lived.” from the report
Environmental hazards
seriousRust, untreated door frames and a poorly defined slope meant parts of the building were not fully safe or easy to clean.
“The main corridor between parts of the building had a poorly defined slope putting people at the risk of trips and falls.” from the report
Infection control
needs fixingSome staff wore nail polish or acrylic nails, and cardboard remained attached to one person's walking frame. These issues could make effective cleaning harder.
“Some staff were wearing nail polish and acrylic nails. This created a potential infection risk especially when supporting people with personal hygiene.” from the report
Medicine instructions
needs fixingThere were no specific instructions for staff about when to give some medicines taken only when needed, such as pain relief.
“Some people took medicines only when they needed them, such as pain relief but there were no specific guidelines for staff on when to administer these.” from the report
Quality checks
needs fixingManagement checks did not consistently identify problems with infection control, equipment, the environment, medicine protocols or staff risk assessments.
“Although regular checks were made to medicines they failed to identify there was a lack of PRN protocols or missing risk assessments on staff files when they were needed.” from the report
- 01Have the rusted equipment, untreated door frames and corridor slope now been repaired, and how are these repairs being checked?
- 02What action has been taken to stop staff wearing nail polish or acrylic nails when supporting people with personal hygiene?
- 03Have written guidelines now been completed for medicines given only when needed, including pain relief?
- 04How does management now check that infection control, equipment and environmental problems are identified and corrected?
- 05How are care plans updated when a person's health advice or fluid requirements change?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 5 October 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.
What inspectors found, February 2022
Rated Requires Improvement; inspectors found kind and responsive care, but serious gaps in safety, risk assessment, consent and management.
This was the home's first inspection. It was unannounced and took place on 05 January 2022. Inspectors spoke with people and staff, reviewed care plans, training and safety records, and checked the building.
The home was not always safe. Inspectors found poor infection control, unsafe or unsuitable parts of the building, missing risk assessments and gaps in safeguarding training. They also found that staff did not always have the guidance and training needed to provide consistent care.
People were treated kindly and with respect. Staff knew people well, supported their choices and helped them keep relationships and interests. Medicines were managed safely, and people generally received personalised care.
The overall rating Requires Improvement means the home was not consistently meeting the required standard. The inspection found breaches of Regulations 11, 12 and 17. The provider said it had started some improvements, and CQC said it would monitor the home and return as part of its re-inspection programme.
Kind and respectful care
Inspectors saw staff treating people with kindness and respecting their dignity, privacy and independence.
“Throughout this inspection we saw people were treated well and with respect by a staff team who understood and supported their dignity.” from the report
Staff availability
There were enough staff to support people promptly. Staff also had time to spend with people without appearing rushed.
“People were supported by enough staff who were available to safely support them.” from the report
Medicines
People received their medicines when needed. Staff were trained and assessed as competent, and the home had systems for responding to errors.
“People's medicines were managed safely. People received their medicines when they needed them.” from the report
Personalised support
People and relatives were involved in care planning. Staff knew people's histories, preferences, health needs and how they wanted to be supported.
“People and, when needed, relatives were involved in the development and review of their own care and support plans.” from the report
Unsafe environment and infection control
seriousInspectors found risks including unsecured electrical and hot water systems, unprotected hot pipes, unsuitable stair gates, damaged fire doors, poorly stored cleaning products and unclean or damaged surfaces. These issues also made it harder to prevent infection.
“People were not always safe as the infection prevention and control procedures were not effectively implemented.” from the report
Incomplete risk assessments
seriousThe home had not consistently assessed risks such as falls, malnutrition, dehydration, skin breakdown and mobility. Staff therefore did not always have clear guidance on how to support people safely.
“People were not consistently supported to identify and mitigate risks associated with their care and support.” from the report
Consent and restrictions
seriousThe home did not properly assess people's mental capacity before making decisions for them or using restrictions such as bed rails. It also accepted some decisions from family members without checking the legal basis or best interests.
“The provider did not complete appropriate assessments of capacity for people.” from the report
Training gaps
needs fixingTraining records showed missing training in areas including safeguarding, infection control, first aid and health and safety. Inspectors said this could lead to inconsistent care.
“This contained several missing training events for staff including (but not limited to) safeguarding adults, infection control, first aid and health and safety.” from the report
Weak quality checks
seriousThe home's monitoring systems did not identify several problems found by inspectors. Feedback was collected, but the home had not communicated what action had been taken.
“The provider did not have effective quality monitoring systems in place to identify and drive improvements.” from the report
- 01Have all individual risk assessments for falls, nutrition, hydration, skin care and mobility now been completed and reviewed?
- 02What changes have been made to the fire doors, hot water pipes, electrical systems, stair gates and storage of hazardous products?
- 03Has the current fire risk assessment been completed, and can you explain how horizontal evacuation would work for residents?
- 04How do you assess mental capacity and best interests before using bed rails or accepting decisions made by relatives?
- 05Have all staff completed safeguarding, infection control, first aid and health and safety training?
This was the home's first unannounced inspection and covered all five key questions, the care provided and the physical premises; the serious injury that partly prompted the inspection was not examined because it was under formal investigation. This explanation was written from the published report of 11 February 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 Standon House
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- October 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- July 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Inspected but not ratedSafe: Inspected but not rated
- January 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2021
Registered with the Care Quality Commission on 31 March 2021.
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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