CQC report explained · a residential care home
What the CQC found at Stilecroft Residential 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
- Staff understood safeguarding responsibilities and people felt safe with staff. However, some health and safety checks, equipment checks and safeguarding records were incomplete or not recorded.
- Effective?
- Requires improvement
- Staff supported people to drink and eat, including people with specialist dietary needs. Records did not always show when nutrition concerns had been referred to professionals or what advice had been given.
- Caring?
- Requires improvement
- Caring was not assessed as part of this targeted inspection.
- Responsive?
- Good
- Responsive care was not assessed as part of this targeted inspection.
- Well-led?
- Requires improvement
- The full Well-led key question was not assessed as part of this targeted inspection.
What inspectors found, November 2022
Stilecroft Residential Home was inspected but not rated; inspectors found kind support with eating and drinking, but gaps in safety and nutrition records.
This was an unannounced targeted inspection. Inspectors visited the home, observed lunchtime, spoke with three people and three staff, and reviewed care and safety records. The inspection focused on safeguarding, managing risks, and making sure people had enough to eat and drink.
People received support with meals and drinks, and staff understood safeguarding responsibilities. However, some safety checks and checks on equipment were not recorded. Fire alarm tests had not been carried out for more than a month, even though the provider said they should happen weekly.
Records about weight loss did not always show when professionals had been contacted or what advice had been given. The manager introduced new recording arrangements after inspectors raised this, but these changes were not yet embedded.
The home was inspected but not rated. Its previous overall rating was Requires Improvement, published in June 2022. A targeted inspection does not change ratings because it does not assess the whole service.
Support with meals and drinks
Staff gave people proactive help at mealtimes and encouraged them to remain as independent as possible. People enjoyed their meals and mealtime experiences.
“People received proactive support from staff at mealtimes to assist them with eating and drinking.” from the report
Staff understood safeguarding
Staff knew how to recognise and report safeguarding concerns. People felt safe and responded positively to staff.
“Staff understood their safeguarding responsibilities; staff knew how to identify and raise any concerns appropriately to protect people from the risk of abuse.” from the report
Falls monitoring
The home had a system for reviewing falls and learning from them to reduce future risks.
“A robust system was in place to review and analyse where people had experienced falls to help lessen risks and inform learning across the service.” from the report
Missed safety checks
seriousSome health and safety checks were not carried out or recorded. Fire alarm tests had not been done for over a month, although the provider's records said they should be weekly.
“For example, fire alarm tests had not been carried out for over 1 month, the provider's records stated this should be checked weekly.” from the report
Incomplete equipment and care checks
needs fixingChecks needed to keep people safe and confirm equipment was working were not always recorded. This included equipment such as sensor mats.
“Checks identified in people's care plans to keep them safe and ensure equipment was working were not always recorded to show these were taking place.” from the report
Nutrition referral records
needs fixingRecords did not always show when professionals had been contacted about weight loss or what advice they had given. New recording methods had started but were not yet established.
“When staff had identified concerns about people's nutrition and weight loss, records did not always clearly identify when referrals had been made to professionals or what advice had been given.” from the report
Safeguarding log
needs fixingThe safeguarding log was not always complete or up to date, so it did not always show that concerns had been recorded and followed up properly.
“The provider's safeguarding log was not always up to date or complete to ensure safeguarding concerns were logged and followed up in-line with the provider's processes.” from the report
- 01How do you now make sure weekly fire alarm tests and other health and safety checks are completed and recorded?
- 02How are sensor mats and other equipment checked, and how can I see that these checks are being completed?
- 03When someone is losing weight, how quickly are referrals made to health professionals and how is their advice recorded and followed?
- 04How do you keep the safeguarding log complete and make sure every concern is followed up?
- 05What evidence can you show that the new nutrition recording arrangements are now embedded?
This was a targeted inspection of safeguarding, risk management, and eating and drinking; the full five key questions were not assessed and the previous ratings were not changed. This explanation was written from the published report of 4 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.
What inspectors found, June 2022
Rated Requires Improvement; inspectors found progress since an Inadequate rating, but medicines, safety, consent and oversight still put people at risk, and the home is no longer in special measures.
This was an unannounced focused inspection on 16 March 2022. Two inspectors visited the home, spoke with six people, five relatives and 11 staff, and reviewed care, medicines, training and management records.
The inspectors found risks with medicines, the building and equipment. Some people did not receive medicines as prescribed, repeated refusals were not always escalated, fire escape staircases and call bells were unsafe, and consent and mental capacity records were incomplete.
There had been clear improvement since the previous inspection, which was rated Inadequate. Staffing, safeguarding, infection control and personalised care had improved. People and relatives also spoke positively about staff and the manager.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were Requires Improvement, while Responsive was Good. The home had been in special measures since September 2021, but left special measures because it was no longer rated Inadequate.
Personalised care
Staff knew people's preferences and life histories and used this knowledge to adapt their care. People formed good relationships with staff.
“People received the personalised support they needed and formed good relationships with the staff supporting them.” from the report
Improved safeguarding
Staff understood how to recognise and report safeguarding concerns. The manager raised concerns appropriately with the local authority.
“Staff knew how to identify and raise any safeguarding concerns.” from the report
Infection control
Inspectors were assured that the home had improved its infection prevention and control arrangements, including use of protective equipment, testing and visiting procedures.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Positive staff culture
The inspection found a significant improvement in the home's culture. Staff worked together and felt able to suggest improvements.
“There had been a significant improvement in the culture of the home.” from the report
Medicines were not always safe
seriousSome people did not receive medicines as prescribed. Repeated refusals were not always followed up, and there was not enough information about some covert medicines and creams.
“People did not always receive their medicines as prescribed.” from the report
Building and equipment risks
seriousFire escape staircases had not been properly maintained and some call bells did not work. The provider took immediate action on some issues, but ongoing checks were still needed.
“external fire escape staircases were unsafe and had not been properly maintained.” from the report
Consent and capacity records
seriousConsent was not always recorded, and capacity assessments were not always clear. Bedrails were not always assessed as a restrictive practice under the Mental Capacity Act.
“People's consent to receive care was not recorded.” from the report
Weak quality checks
seriousThe home's monitoring systems did not identify important problems found by inspectors. Issues from the previous inspection had not all been dealt with.
“The provider's quality assurance systems had failed to identify the issues we found on inspection, such as with medicines, the environment and MCA.” from the report
Dementia care plan
needs fixingRecommendations from the previous four inspections about dementia care had not been met. The provider had not finalised its dementia care strategy.
“The provider had not finalised their dementia care strategy to establish their approach for supporting people living with dementia.” from the report
- 01What has been done to make the fire escape staircases, fire exit doors and call bells safe and reliable?
- 02How do you now record and escalate repeated refusals of medicines?
- 03How do you check that medicines, including covert medicines and creams, are given in line with instructions?
- 04How are consent and mental capacity decisions recorded now, including decisions about bedrails?
- 05What is the current dementia care strategy, and how are you checking that it is being followed?
This was a focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected in this visit, and the report says ratings for key questions not inspected carry over from the last inspection. This explanation was written from the published report of 17 June 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 Stilecroft Residential Home
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- November 2022Inspected but not ratedcurrent ratingSafe: Inspected but not ratedEffective: Inspected but not rated
- June 2022Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- October 2021Inadequatedown from GoodSafe: InadequateEffective: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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