CQC report explained · a residential care home
What the CQC found at Stinchcombe Manor
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, effective medicines management and suitable infection prevention measures. Staff understood individual risks and how to support people who became anxious or distressed.
- Effective?
- Good
- This key question was not inspected during this focused visit. The previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. The previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. The previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Management systems did not always identify or address environmental risks, incomplete care records and reporting requirements. The provider had breached Regulation 17 on good governance.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found safe care and kind support, but weaknesses in records, checks and management systems.
This was an unannounced focused inspection on 28 and 29 March 2023. Inspectors reviewed Safe and Well-led only. They spoke with seven people, one relative, nine staff and three healthcare professionals, and checked six people's care records and management records.
The home was rated Good for Safe. Inspectors found enough staff, safe recruitment, effective medicines management and good infection prevention. Staff understood people's risks and knew how to support people when they became anxious or distressed.
The home was rated Requires Improvement for Well-led. Some care records and assessments were incomplete, and audits had not found or fixed all environmental and reporting problems. The overall rating is Requires Improvement. The report says the previous rating was Good, while the Well-led rating fell from Good to Requires Improvement.
Medicines
Inspectors found medicines were stored safely and given as prescribed. Staff had received training and guidance, including on medicines given when needed.
“People's medicines were stored safely, and they had received their medicines as prescribed.” from the report
Understanding people’s risks
Staff understood people's individual risks and knew how to reassure them when they were anxious or distressed.
“Staff understood people's individual care risks and were able to discuss the support they required.” from the report
Activities and relationships
People enjoyed activities with staff and spoke positively about living in the home. Inspectors also saw people and staff spending time together.
“On both days of the inspection people were enjoying games and activities with staff.” from the report
Staffing and recruitment
Inspectors saw enough staff to meet people's needs, and recruitment checks were completed before new staff started.
“On both days of the inspection we observed there were enough staff to meet people's needs.” from the report
Management checks
seriousThe provider's audits had not identified all environmental risks or ensured that concerns were corrected. This was part of the breach of good governance.
“The provider's audits and management systems had not identified concerns which could place people at risk from their environment.” from the report
Incomplete care records
needs fixingSome care plans and assessments did not fully reflect people's needs. The issue had already been found in a February 2023 audit but had not been fixed by the inspection.
“Some assessments we found at this inspection were incomplete and not always reflective of people's needs.” from the report
Incident reporting
seriousThe provider did not always consistently inform CQC and local safeguarding services about notifiable incidents. The report said the external reporting systems were not fully embedded.
“The provider and registered manager did not always operate effective systems to ensure that CQC and local authority safeguarding were consistently informed of notifiable incidents at the home.” from the report
- 01Have all incomplete care plans and assessments now been completed and checked against each person's current needs?
- 02What new environmental checks are now used, including checks on window restrictors and other areas that could pose a risk?
- 03How do you make sure notifiable incidents are consistently reported to CQC and local safeguarding services?
- 04What actions were included in the provider's action plan, and what evidence can you show that they are complete?
- 05How will you monitor whether the management and audit systems are working over time?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 18 May 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, July 2022
Stinchcombe Manor was rated Good; inspectors found safe, kind care, but some new monitoring systems were not yet used consistently.
This was an unannounced follow-up inspection on 7 and 8 June 2022. One inspector observed people and staff, spoke with staff and social care professionals, and checked care, medicines and management records.
The overall rating was Good. Safe was rated Good and the report also records Well-led as Good. Inspectors found enough staff, safe medicines practice, risk assessments and kind interactions. People appeared relaxed and comfortable around staff.
The home had improved since the previous inspection, which was rated Requires Improvement. The provider was no longer in breach of the rules about safe care and treatment or good governance.
Some monitoring systems had only recently been introduced and were still being embedded. Inspectors also said safety checks linked to legionella and infection prevention in the premises needed continued attention.
Enough staff
Inspectors found staffing levels were planned around people's needs. Staff were available and responded promptly to requests for help.
“There were enough staff to meet people's needs.” from the report
Kind interactions
People appeared relaxed and comfortable around staff. Inspectors saw caring and kind interactions.
“We observed people to be relaxed and comfortable around staff and staff were caring and kind in their interactions.” from the report
Safe medicines
Records showed people received their medicines as prescribed. Staff had been trained and assessed as competent before administering them.
“Records showed people had received their medicines as prescribed.” from the report
Improved oversight
A new audit system gave the provider better oversight of risks and quality concerns. Plans were in place when checks found shortfalls.
“A new audit system was in use which enhanced the provider's oversight of the service and supported the registered manager to monitor risk and quality concerns in the service.” from the report
Monitoring not yet consistent
needs fixingThe provider was still embedding some new monitoring systems. Inspectors said processes needed to be followed more robustly and consistently in daily practice.
“However, we found improvements were required to ensure processes were followed robustly and consistently as part of daily practice.” from the report
Some safety records
needs fixingAction had been taken on legionella risks, but the provider was still working to make sure completed safety checks were always recorded.
“Action had been taken to reduce the risks related to legionella and the provider was working to ensure completed safety checks were always recorded.” from the report
Premises infection control
needs fixingThe inspectors were only somewhat assured about safety linked to the layout and hygiene practices of the premises.
“We were somewhat assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
- 01How are you now making sure the new audit and monitoring systems are followed consistently every day?
- 02How do you record completed legionella and other environmental safety checks, and can we see recent examples?
- 03What improvements have been made to the layout and hygiene practices of the premises since the inspection?
- 04How often are fire drills carried out, and are all staff familiar with evacuation equipment and fire extinguishers?
- 05How do you review people's behaviour support plans when their needs change?
This was an unannounced follow-up inspection focused on Safe and Well-led; the report does not give new ratings for Effective, Caring or Responsive. This explanation was written from the published report of 23 July 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 Stinchcombe Manor
5 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2022Goodup from Requires improvementSafe: GoodWell-led: Good
- February 2022Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- October 2021InadequateSafe: InadequateWell-led: Inadequate
- December 2020Inspected but not ratedSafe: Inspected but not rated
- October 2019GoodSafe: GoodWell-led: Good
- September 2018
Registered with the Care Quality Commission on 4 September 2018.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
38 live-in carers within about an hour of Gloucestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.