CQC report explained · a residential care home
What the CQC found at Stoke View 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
- Some risks, including epilepsy, self-harm, fire safety and risks to others, were not clearly assessed or managed. The home could not show how many funded one-to-one hours people received, and records for homely remedies needed improvement.
- Effective?
- Requires improvement
- The home did not always follow the Mental Capacity Act or properly record best-interest decisions. Some restrictions were not recognised as restrictive practice, and some DoLS authorisations were not reviewed.
- Caring?
- Good
- This question was not inspected during this focused visit. Inspectors nevertheless found that staff knew people well, respected them and provided caring and compassionate support.
- Responsive?
- Good
- This question was not inspected during this focused visit. The report says people could choose how to spend their time and take part in activities and interests.
- Well-led?
- Requires improvement
- Quality checks did not reliably identify problems with risks, staffing, money, consent, records or significant events. The provider had also failed to notify CQC about some significant events.
What inspectors found, September 2023
Rated Requires Improvement; inspectors found caring staff and safe medicines, but concerns about risk management, people's rights and governance.
This was a focused inspection after concerns about safeguarding, staffing, people's money, restrictive practices and how the home was managed. Two inspectors visited on 14 and 15 August 2023. They spoke with people, staff, relatives and other professionals, and checked care records, medicines, training and management records.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were each rated Requires Improvement. Inspectors found that people were not always protected from avoidable harm, care records did not always contain the information staff needed, and legal checks about consent and restrictions were not always completed.
There were also positive findings. People said they felt safe, staff knew them well and provided caring support, medicines were managed safely, and people could choose how to spend their time. The home was clean and well maintained, and relatives knew how to raise concerns.
The rating had fallen from Good at the previous inspection, published in March 2019. The provider must send an action plan, and CQC will work with the local authority and monitor progress before the next inspection.
Caring relationships
Staff knew people well and inspectors saw evidence of respectful, compassionate relationships. People and relatives said they felt safe and were happy with the support.
“The culture of the service was caring, staff talked about people in a person-centred way, it was clear that staff knew people well and genuinely cared about the people they supported.” from the report
Medicines
Prescribed medicines were stored and administered safely. Staff were trained and their competence was checked regularly.
“There were systems in place to audit medication practices and clear records were kept showing when prescribed medicines had been administered or refused.” from the report
Health support
People could access GPs, dentists and hospital specialists. Staff worked with outside professionals to support people's health.
“People were supported to access a range of health care professionals to enable them to live healthier lives.” from the report
Home environment
The home was clean, uncluttered and maintained. People's bedrooms were personalised to reflect their interests.
“The service continued to be well maintained was homely, clean and free from clutter.” from the report
Open feedback
People and relatives knew how to complain and felt they would be listened to. Staff also said they felt supported by managers.
“People and their relatives told us they were aware of how to make a complaint and felt able to raise concerns if something was not right.” from the report
Incomplete risk information
seriousSome care plans and risk assessments did not explain current risks or how staff should manage them. This included epilepsy, self-harm, fire safety and risks to others.
“The provider had failed to ensure that risks relating to the management of people's complex needs were being effectively mitigated and managed.” from the report
Consent and restrictions
seriousThe home did not always assess people's capacity or record best-interest decisions. Some restrictions, including constant supervision and limits on smoking, were not properly recognised or legally reviewed.
“There was no legal framework in place to support these restrictions.” from the report
Management of people's money
seriousThe home recorded only some one-to-one support hours and could not show how many hours people had received. This meant charges could not be checked properly and people risked financial disadvantage.
“This meant they were unable to demonstrate that any charges had been correctly applied, which placed people at risk of being financially disadvantaged.” from the report
Weak quality checks
seriousGovernance systems did not reliably find or correct problems with risks, staffing, care records, incidents and staff competence. Monthly key worker review meetings had also stopped without the provider identifying this.
“Systems were either not embedded into practice or undertaken robustly enough to identify and monitor the quality of the service and effectively drive improvements.” from the report
Staffing information
needs fixingManagers could not say how many one-to-one or two-to-one hours were funded for people. This meant they could not be sure staffing levels were sufficient for assessed needs.
“This meant they could not be assured they had sufficient staff available to meet people's assessed needs.” from the report
- 01What action have you taken to make sure every person's current risks, including epilepsy, self-harm and fire safety, are clearly recorded for staff?
- 02How do you now assess capacity and record best-interest decisions for people's finances, supervision, smoking and other restrictions?
- 03How do you check that DoLS authorisations and other restrictions are reviewed when required?
- 04How do you record all funded one-to-one and two-to-one hours, and how do you use this information to set staffing levels?
- 05How are your quality checks now identifying problems with care records, incidents, staff competence and notifications to CQC?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward when the overall rating was calculated. This explanation was written from the published report of 26 September 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, March 2019
Stoke View Residential Home was rated Good; inspectors found safe, kind and personalised care, with communication about complaints needing attention.
This was an unannounced comprehensive inspection on 23 February 2019. One inspector met all nine people living in the home, observed daily care, spoke with the provider, manager and staff, and received feedback from one relative.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines arrangements, suitable training, good healthcare support and detailed personal care plans.
The report says the home had remained Good since the previous inspection on 6 September 2016. Some people had limited communication, so inspectors also relied on observations, records and feedback from staff and a relative.
Safe staffing and risk management
Inspectors found enough staff and clear systems for managing people's risks. Recruitment checks were completed and staff knew how to respond to possible abuse.
“People had their needs met by sufficient numbers of staff to support them.” from the report
Safe medicines
Staff received medicines training and their work was checked. Records and guidance were in place for medicines taken when needed.
“People received their medicines safely from staff who had completed training.” from the report
Kind relationships
Staff knew people well and supported them with patience, compassion and reassurance. People appeared relaxed and comfortable with staff.
“People were supported by staff who were both kind and caring and we observed staff treated people with patience and compassion.” from the report
Personalised communication
Staff adapted how they communicated, including using signs, simple questions and visual choices. Care records described people's preferred routines and support.
“People's communication needs were effectively assessed and met by staff.” from the report
Clear oversight
The provider and manager used audits, meetings and checks to monitor care and identify improvements. Staff described the leadership as approachable.
“The provider provided clear leadership and governance; ensuring the service was overseen to maintain quality.” from the report
Understanding complaints
minorA complaints procedure was available in an easy-read version, but some people would not fully understand it because of their learning disability. The provider said the policy would be reviewed to ensure it met communication requirements.
“Some people currently living in the service would not fully understand the procedure due to the level of their learning disability.” from the report
- 01How do you help people who use non-verbal communication to make a complaint or show that something is wrong?
- 02Has the complaints policy been reviewed since this inspection to ensure it meets people's communication needs?
- 03How are people's communication methods, preferred routines and changing needs kept up to date in their care plans?
- 04How do you check that medicines taken when needed are given safely and only when appropriate?
- 05How are relatives or advocates involved when people cannot fully express their views about their care?
This was an unannounced comprehensive inspection covering all five CQC questions and both the accommodation and care provided. This explanation was written from the published report of 21 March 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 Stoke View Residential Home
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- March 2013
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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