CQC report explained · a residential care home
What the CQC found at Stanwell Rest Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risks were not properly assessed or updated, and medicines were not always managed safely. Staff knew people well, and the home had enough suitably qualified staff rostered during the inspection.
- Effective?
- Requires improvement
- Mental capacity assessments and best-interest decisions were not consistently completed in line with the law. People enjoyed the food, received support with their health needs and had staff training in place.
- Caring?
- Good
- This question was not inspected during this visit, so no new rating was given.
- Responsive?
- Good
- This question was not inspected during this visit, so no new rating was given.
- Well-led?
- Requires improvement
- Audits and management checks had not identified or corrected several problems with care records, medicines and risk management. Staff said they felt supported and could raise concerns.
What inspectors found, February 2023
Rated Requires Improvement; inspectors found ongoing problems with medicines, risk assessments, consent decisions and care records.
This was an unannounced inspection on 7 and 12 December 2022. Inspectors spoke with people, relatives and staff, observed care, reviewed care plans, risk assessments and 12 medicines records, and checked the home's audits and recruitment records.
The home was not always safe. Some risks were not fully assessed or kept up to date. Medicines were not always stored, recorded or managed safely. The home had enough staff on the inspection days, and staff knew people well and understood safeguarding.
The home was not always effective. Mental capacity assessments and best-interest decisions were not consistently completed when people could not make particular decisions. People enjoyed the food and could access healthcare, but some nutrition monitoring was not up to date.
The home was not always well-led. Audits had not identified important problems in care records, medicines and risk management. The overall rating remained Requires Improvement, the same as at the previous inspection in 2019.
Staff knew people well
Staff understood people's needs and knew how to keep them safe. People and relatives said they felt safe with the care.
“People were supported by staff who knew them and their needs well.” from the report
Food and mealtimes
People told inspectors they enjoyed the food. Mealtimes were observed to be relaxed and sociable, with choices about where to eat.
“People we spoke with told us they enjoyed their meals and we observed mealtimes to be sociable and relaxed.” from the report
Health care support
The home sought advice from health professionals and records showed contact with GPs and the community district nursing team when needed.
“We reviewed people's care records which demonstrated the service sought timely and appropriate advice and guidance from health professionals” from the report
Infection control
Inspectors were assured that the home managed infection risks, used protective equipment safely and had arrangements for visitors and possible outbreaks.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Improvements to the building
The home had made changes to help people with dementia find their way around and move safely. Further work was still in progress.
“At this inspection we noted improvements had been made to support people to identify different aspects of the home.” from the report
Risk assessments
seriousSome assessments and plans were incomplete, out of date or gave an inaccurate level of risk. This included risks linked to diabetes, seizures, choking and falls.
“Some risk assessments and management plans for individuals were not detailed, complete or up to date.” from the report
Medicines management
seriousThe home did not always record storage temperatures, opening dates or the application of creams. Some medicine plans and instructions were incomplete.
“We found improvements were required to ensure people's medicines were stored and managed safely, and in line with manufacturers advice.” from the report
Consent and involvement
seriousThe home did not consistently assess whether people could make specific decisions or record best-interest decisions. Some relatives said they were not included in decisions.
“The principles of the MCA were not always consistently applied.” from the report
Incomplete care records
needs fixingSome care plans contained information that was out of date or had not been updated consistently. This meant staff sometimes relied on knowing people personally to provide safe care.
“We found multiple examples where people's records were not clear, accurate or contemporaneous.” from the report
Weak oversight
needs fixingAudits had not found the problems identified by inspectors. The home also failed to notify the CQC about two concerns until after inspectors raised the issue.
“Systems and processes to assess, monitor and review records related to people's care failed to identify findings from this inspection” from the report
- 01What changes have been made to medicine storage temperatures, opening-date records, topical cream records and PRN medicine instructions?
- 02How do you now check that risk assessments for falls, choking, seizures and diabetes are accurate and up to date?
- 03How do you assess capacity for each specific decision and record best-interest decisions?
- 04How will relatives be involved when a person cannot make a particular decision?
- 05How often are care records and audits checked, and how do you make sure problems are identified and corrected?
This inspection covered Safe, Effective and Well-led; Caring and Responsive were not inspected and the report says the other ratings carry over from the last inspection. This explanation was written from the published report of 22 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, August 2019
Rated Requires Improvement; inspectors found kind, personalised care, but serious weaknesses in medicines, consent and records.
Inspectors visited unannounced on 13 and 17 May 2019. They spoke with people living in the home, relatives, staff and healthcare professionals. They observed care and checked records, medicines, staffing, premises, complaints and quality checks.
The home was caring and responsive. Staff knew people well, treated them kindly and supported independence, activities and personal choices. There were enough staff at the time of the inspection, and staff recruitment checks were robust.
However, some safety and management systems were not reliable. Medicines records had gaps, some medicines were given without clear consent or capacity assessments, and risk plans and quality checks did not always identify problems. The premises were not fully dementia-friendly.
The overall rating was Requires Improvement. Safe, Effective and Well-led were also Requires Improvement, while Caring and Responsive were Good. The home had previously been rated Good in November 2016, so the overall position had worsened.
Kind and respectful staff
Staff were caring and empathetic. They knew people well and respected their dignity, privacy and personal choices.
“Staff were respectful of people and treated them with kindness and compassion.” from the report
Promoting independence
The home encouraged people to do things for themselves and used equipment to support safe independence.
“People were supported to be as independent as possible in all elements of their care” from the report
Personalised activities
Activities were based on people's interests, abilities and preferences. People who did not like group activities could have one-to-one time.
“There was a schedule with changing themes and a range of activities to appeal to different people.” from the report
Enough staff at the inspection
Inspectors found enough staff to keep people safe and meet their needs. Recruitment checks included references and DBS checks.
“There were sufficient numbers of staff deployed to keep people safe and meet their needs.” from the report
Support with food and drink
People's nutrition and hydration risks were assessed and monitored. Staff provided patient support where people needed help to eat or drink.
“Where people needed help to eat or drink, staff provided this support in a patient and caring way.” from the report
Medicines records and storage
seriousMedicines administration records contained errors and gaps. The medicines cabinet key was accessible to all staff, reducing accountability.
“Medicines were not always managed in line with regulations and best practice guidance.” from the report
Medicines and consent
seriousSome medicines were given crushed in food or covertly without clear capacity assessments, records or proper consent. This was a breach of Regulation 11.
“Medicines were administered without obtaining proper consent or assessing the person's capacity to consent.” from the report
Risk assessments
seriousSupport plans did not always explain clearly how staff should reduce risks. One plan did not state that a person with seizures must not be left alone in the bath.
“support plans were not always detailed enough to ensure staff understood how to mitigate risks and keep people safe.” from the report
Quality checks and records
seriousThe home's checks did not identify all the problems found by inspectors, and records were not always complete or accurate. This was a breach of Regulation 17.
“Governance processes were not robust enough to ensure people's risks had been fully considered and minimised.” from the report
Dementia-friendly premises
needs fixingSome doors were not clearly labelled, a corridor slope was not obvious, and some areas needed replacement or repair. CQC recommended fully implementing dementia-friendly premises guidance.
“Not all doors were labelled or signposted, so bedrooms, living spaces and toilets were not easily distinguished.” from the report
Communication with professionals
needs fixingSome healthcare professionals said communication from the home was delayed or unclear. The manager acknowledged this needed improvement.
“There was some less positive feedback from other professionals who told us that communication from the service was often delayed or unclear.” from the report
- 01What changes have been made to medicines records, storage and audits since the inspection?
- 02How do you now assess capacity and record consent before giving medicines crushed in food or covertly?
- 03How are individual risks, including seizures and bathing, recorded and checked in each person's care plan?
- 04What improvements have been made to signs, floor markings and other dementia-friendly features?
- 05How do you check that quality audits identify incomplete records and other safety problems?
This was an unannounced inspection of the care and accommodation, covering all five CQC questions and the overall rating. This explanation was written from the published report of 7 August 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.
Every inspection of Stanwell Rest Home
6 rated inspections over 8 years: the service has improved, from Inadequate to Requires improvement.
- February 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016Requires improvementstayed Requires improvementWell-led: Requires improvement
- October 2015Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2015InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- October 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 January 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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