CQC report explained · a residential care home
What the CQC found at Stonebow House 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
- Inspectors found medicines were not always managed safely, some windows were not secured with restrictors, and some areas were unclean. They also found safeguarding systems, staffing and recruitment were in place.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Well-led?
- Requires improvement
- The management team and governance systems were in place, but audits had not identified problems with window restrictors, medicines management and cleanliness.
What inspectors found, January 2024
Rated Requires Improvement; inspectors found kind care and enough staff, but medicines, cleanliness, risk checks and management oversight needed improvement.
This was an unannounced, focused inspection on 16 November 2023. Inspectors looked at the Safe and Well-led areas because of concerns about risk management and oversight. They spoke with people, relatives, staff and visiting health professionals, and reviewed care, medicines, staff and management records.
The home was not always safe. Inspectors found medicines were not always managed safely, some windows did not have restrictors, and some bedrooms, bathrooms and carpets were unclean. They also found gaps in documentation about the locked front door and whether people could leave the property.
There were positive findings. People said they felt safe, staff were described as kind and caring, staffing and recruitment processes were suitable, and the home had an open culture. However, internal audits had not found several of the problems identified during the inspection.
The overall rating changed from Good at the previous inspection to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were carried forward.
People felt safe
People and relatives said they felt safe and believed concerns would be listened to. Staff had safeguarding training and knew how to raise concerns.
“People told us they felt safe living at the home, relatives spoke positively about their loved one's care.” from the report
Kind and caring staff
Inspectors saw staff being kind and caring. People and relatives also described staff as helpful, patient, respectful and caring.
“A person told us, "The staff here are very helpful and patient".” from the report
Suitable staffing and recruitment
The provider had enough staff and carried out checks before employing new staff. New staff completed induction, shadowing and competency assessments.
“The provider ensured there were sufficient numbers of suitable staff. The provider operated safe recruitment processes.” from the report
Open culture and partnership working
Relatives, staff and professionals described good communication and collaboration. The home also worked with health and care professionals to support people.
“There was a positive and open culture at the service.” from the report
Medicines were not always safe
seriousStaff needed more knowledge about medicines and their side effects. Some medicines did not have opening dates, returned medicines were not stored effectively, and bowel monitoring and PRN instructions needed more detail.
“People were supported to receive their medicines in a way which was not always safe.” from the report
Some environmental risks
seriousSome windows did not have restrictors or a risk assessment. The provider began fitting the restrictors during the inspection.
“This meant people were at increased risk of harm.” from the report
Cleanliness needed improvement
needs fixingCleaning schedules were in place but had not ensured that all areas were clean. Inspectors found some bedrooms, bathrooms and carpets were unclean.
“We were not always assured the provider was promoting good hygiene practices.” from the report
Management checks missed problems
needs fixingInternal audits did not identify several issues found by inspectors, including missing window restrictors, medicines concerns and cleanliness problems.
“The provider and registered manager completed internal audits; however these had not always identified the concerns we found during the inspection.” from the report
Mental Capacity Act records
needs fixingThe locked front door had not been supported by the required authorisations or explanations in people's care plans. The manager said they would complete the documentation and best-interest decisions.
“The provider had not completed the relevant authorisations, or documented in people's care plan's the reason for the restriction.” from the report
- 01Have all window restrictors now been fitted, and has the home completed risk assessments for the windows?
- 02What extra training have staff received about medicine types, side effects and PRN medicines?
- 03How are medicine opening dates, expiry dates, returned medicines and the medicines trolley now checked?
- 04What action has been taken to improve cleaning in bedrooms, bathrooms and carpets?
- 05How are managers checking that audits identify and fix safety and cleanliness problems?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 19 January 2024 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 2021
Rated Good; inspectors found safe, kind and well-managed care, with some infection-control and premises work still needed.
This was an unannounced focused inspection on 22 July 2021. Two inspectors spoke with people living at the home, staff, relatives and a health professional. They also reviewed care, medicines, staffing, recruitment, maintenance, complaints and management records.
The home was rated Good overall. Safe, effective, caring and well-led were all rated Good. Inspectors found improvements since the previous inspection, including better risk management, medicines systems, staffing support and involvement of people in decisions about their care.
Some work was still needed. Inspectors found porous bathroom surfaces, a ripped stair lift seat, no hot water in one rest room and room to improve how staff used protective equipment. The manager agreed to address these issues.
Improved safety
Inspectors found that risks linked to the building, equipment and medicines were being managed better than at the previous inspection.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Caring relationships
People were comfortable with staff, and relatives spoke positively about the care and relationships at the home.
“People were at ease with the staff caring for them.” from the report
Choice and independence
People were involved in everyday decisions and in choices about the environment. Staff supported independence, including through activities and some self-administration of medicines.
“People were encouraged to make decisions about their day to day care.” from the report
Supportive management
The manager and provider used audits and feedback to make improvements. Staff said managers were approachable and relatives said communication was good.
“The registered manager and provider now regularly checked key areas of the safety and quality of care.” from the report
Premises and infection control
needs fixingSome bathroom surfaces were porous, a stair lift seat was ripped and one rest room had no hot water. Inspectors also said staff needed to improve how they put on and remove protective equipment.
“We were somewhat assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Food and drink records
needs fixingOne relative had raised concerns about whether their family member was supported to eat enough and how this was recorded. Senior staff were working to resolve this.
“Another relative told us they had recently had some concerns regarding the way their family member was supported to have enough to eat, and how this was recorded.” from the report
- 01Have the porous bathroom surfaces, ripped stair lift seat and lack of hot water in the rest room now been fixed?
- 02How are staff's protective equipment skills checked and refreshed?
- 03How do you record and review whether each person has eaten and drunk enough?
- 04What changes were made after the previous breaches of Regulations 12 and 17?
- 05How are people and relatives involved in decisions about care, activities and the home's environment?
This was a focused follow-up inspection of Safe and Well-led, with infection prevention and control also checked; Effective and Caring were re-rated, while ratings for areas not looked at were carried over from the previous inspection. This explanation was written from the published report of 21 August 2021 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 Stonebow House Residential Home
6 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Stonebow House Residential Home →
- August 2021GoodSafe: GoodWell-led: Good
Read what inspectors found at Stonebow House Residential Home →
- January 2021Inspected but not ratedSafe: Inspected but not rated
- May 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementWell-led: Requires improvement
- June 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 23 November 2010.
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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