CQC report explained · a residential care home
What the CQC found at Stone Gables Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found unsafe medicines and staffing, with inadequate leadership and risks to people's care.
This was an unannounced inspection after concerns about medicines and staffing. Inspectors spoke with people, relatives and staff, reviewed care and medicines records, observed care and medicines administration, and checked staff and management records.
The inspectors found problems with medicines, risk assessments, staffing levels and food and drink support. Some records were incomplete or not available, and staff did not always receive enough supervision or support. The home had systems for safeguarding referrals, recruitment and health professional involvement, but follow-up and learning were not reliable.
All five areas were rated Requires Improvement except Well-led, which was rated Inadequate. The overall rating changed from Good at the previous inspection, published in November 2019. The CQC identified breaches of regulations covering safe care, staffing and governance.
Activities
People and relatives took part in activities during the inspection. The activities programme was varied and well attended.
“We observed people and relatives engaging in activities throughout the day.” from the report
Kind staff
Inspectors saw staff treating people kindly and respectfully. Relatives also spoke positively about care staff.
“Our observations showed staff were kind and respectful to people, but were very busy and task orientated.” from the report
Health support
People were supported by a range of health and social care professionals, with weekly reviews and further referrals when needed.
“People received health and social care support from a range of professionals including GP's, district nursing and social work teams.” from the report
Care assessments
People's needs were assessed before they moved in, and care plans included guidance for staff. Relatives were involved in changes to care planning.
“Care plans included information and guidance on how staff should meet people's needs.” from the report
Mental capacity
Inspectors found evidence of applications and authorisations under the relevant safeguards. Decisions were made with people and relatives where needed.
“Where people had been unable to make their own specific decisions, they had been made in line with the MCA and involved people and their relatives.” from the report
Medicines
seriousMedicines were not always given as prescribed or at the correct times. Guidance, dose records and storage arrangements were also not always safe.
“Medicines which must be given at specific times were not always given at those times which meant they may not be fully effective.” from the report
Risk management
seriousRisks linked to behaviour, health and emergency evacuation were not always clearly assessed or managed. Staff could not readily access all risk assessments.
“We found no evidence people were harmed, however, risks to people were not clearly identified or managed.” from the report
Staffing and mealtimes
seriousPeople, relatives and staff felt there were not enough staff. Inspectors saw people at lunch without the help they needed with food.
“SOFI was completed during lunch time, we found a lack of interaction with people and people's needs were not met, for example food was not cut up or people were not supported to eat.” from the report
Management oversight
seriousQuality checks were missing or ineffective and did not reflect the problems inspectors found. Managers also did not provide some requested evidence.
“The few audits that were completed were not effective and did not reflect the concerns we found during the inspection in relation to risk management, ensuring safeguarding procedures were in place, medicines and staff deployment.” from the report
Care records and complaints
needs fixingDaily records did not always show what care had been provided, and the complaints system was not provided to inspectors. End of life wishes were also not always recorded.
“We asked about the system in place for dealing with complaints or concerns, this was not provided.” from the report
Staff support
needs fixingStaff did not receive regular supervision or appraisals, and inspectors found no evidence of the competency assessments described by the manager.
“Staff did not receive regular supervisions or appraisals.” from the report
- 01What changes have been made to ensure medicines, including time-specific and when-required medicines, are given safely and recorded correctly?
- 02How many staff are scheduled on each shift, and how will you ensure people receive enough help at mealtimes?
- 03Where can staff find each person's current risk assessments, including risks linked to behaviour, weight loss and emergency evacuation?
- 04What regular supervision, appraisal and competency checks do staff now receive?
- 05Can you show us the current complaints process and explain how complaints, safeguarding actions and incidents are followed up?
This was an unannounced full inspection covering all five key questions, prompted by concerns about medicines and staffing. This explanation was written from the published report of 28 July 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, December 2020
Inspected but not rated; inspectors were assured the home had suitable infection control measures in place.
This was an announced, targeted inspection on 9 December 2020. It followed concerns about infection prevention and control. Inspectors looked at how the home was preventing and managing infections.
Inspectors found the home was clean and well ventilated. Staff understood infection control procedures, used protective equipment safely and had access to hand-sanitising points. The home was also taking part in regular testing.
The inspection did not give an overall quality rating or a rating for Safe. It recorded that inspectors were assured about infection prevention and control. The provider was signposted to resources to develop its approach.
Protective equipment
Staff demonstrated that they knew how to use PPE. Hand-sanitising points were available before entering and inside the home.
“Staff confidently demonstrated how they used personal protective equipment (PPE) and hand sanitising points were readily accessible before entering and in the home.” from the report
Clean environment
The home was clean and well ventilated, with regular cleaning intended to reduce infection risks.
“The home was well ventilated and clean; regular cleaning procedures were in place to minimise the risk of infection.” from the report
Testing and infection procedures
Staff understood and followed infection control procedures. The service took part in regular testing and supported people with this.
“The service engaged with a regular testing programme and staff were positive in their approach to supporting people with this process.” from the report
Family contact
People were supported to stay in touch with relatives using video links and personalised Christmas cards.
“People were encouraged and supported to keep in contact with family through video links.” from the report
Further development identified
minorInspectors signposted the provider to resources to develop its infection control approach. The report does not say that this was a breach or enforcement action.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01What infection control approach has been developed since inspectors signposted the provider to further resources?
- 02How are PPE use, hand sanitising and regular cleaning checked now?
- 03How does the home arrange testing for people living here and for staff?
- 04How are visitors managed, and how are shielding and social distancing arrangements applied?
- 05How will my relative be supported to keep in contact with family?
This was a targeted inspection of infection prevention and control under Safe; the other key questions and an overall rating were not assessed. This explanation was written from the published report of 22 December 2020 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 Stone Gables Care Home
2 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2020Inspected but not ratedSafe: Inspected but not rated
- November 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2019
Registered with the Care Quality Commission on 19 August 2019.
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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