CQC report explained · a residential care home
What the CQC found at Stonedale Lodge Care Home
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, June 2024
Rated Inadequate and placed in special measures; inspectors found unsafe care, poor oversight and dignity concerns despite kind staff.
This was an unannounced inspection. Inspectors visited on 7 and 12 December 2023, then reviewed information remotely. They spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was rated Inadequate overall. Safe and well-led were rated Inadequate. Caring was rated Requires Improvement. Inspectors found risks were not always assessed or managed, medicines were not always handled safely, and safeguarding procedures were not always followed.
People were not always treated with dignity. Some people looked unkempt, records used disrespectful wording, and there were concerns about oral care, bedding and keeping people warm. Inspectors also found that quality checks had failed to identify important problems.
There were some positive findings. People said they felt safe and liked the staff. Staff were described as kind and caring, recruitment checks were completed, infection control arrangements were adequate, and the home was working within the principles of the Mental Capacity Act.
Kind staff
People said they liked the staff and felt well cared for. Inspectors also observed staff interacting kindly and found staff knew the people they supported.
“Everyone else we spoke with described the staff as 'kind' and 'caring'.” from the report
People felt safe
People and relatives told inspectors they felt safe at the home.
“People told us they felt safe at the home.” from the report
Recruitment checks
The home completed checks to assess whether staff were suitable to work with vulnerable adults.
“Staff were recruited safely after checks had been undertaken on their suitability to work with vulnerable adults.” from the report
Mental capacity practice
Inspectors found that the home was working within the Mental Capacity Act principles and that required legal authorisations were in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
Risks were not managed
seriousRisk assessments and care records did not always reflect people's current needs. Inspectors found concerns involving blood pressure, choking, diets, diabetes and falls.
“Risks to people's wellbeing and clinical needs were not always being assessed, mitigated or managed.” from the report
Medicines were not always safe
seriousSome prescribed medicines were not available, and instructions or records for medicines given through feeding tubes, patches and creams were incomplete.
“Prescribed medicines were not always available to be given to people as there was no stock in the home.” from the report
Safeguarding failures
seriousSafeguarding systems existed but were not used effectively. Inspectors found missed opportunities to protect people from possible harm.
“There were systems and processes in place to help identify and report abuse. However, these were not always being used effectively” from the report
Dignity and personal care
seriousSome people looked unkempt, oral care was not always offered at suitable times, and some bedding was stained. Some care records used disrespectful wording.
“People were not always being cared for in a dignified way.” from the report
Weak management checks
seriousAudits and governance checks did not identify important problems. This was the third consecutive breach relating to governance.
“However, governance systems remained ineffective as they were not thorough enough.” from the report
Staffing pressure
needs fixingThe home identified enough staff using its dependency tools, but some staff said they had to manage with the numbers available when people's needs were high.
“However, some staff told us they had to 'make do' as there was not always enough of them to provide the required level of care.” from the report
- 01What has been done to make sure every person's risk assessment reflects their current needs, including risks involving choking, diabetes, falls and blood pressure?
- 02How do you make sure all prescribed medicines are in stock and that medicines given through feeding tubes, patches and creams are recorded correctly?
- 03What immediate changes have been made to protect people from abuse or harm, and how are safeguarding concerns now checked?
- 04How are you making sure people receive timely oral care, clean bedding, help with personal presentation and support to stay warm?
- 05How will you show families that audits now identify and fix problems with care plans, medicines, infection control and daily records?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 29 June 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, June 2023
Rated Requires Improvement; inspectors found kind care and some progress, but risks, medicines and management systems were still not reliable.
This was an unannounced focused inspection. Inspectors visited on 23 March 2023 and reviewed records, medicines, staffing, infection control and how the home was managed. They spoke with people, relatives and staff and observed care.
The home had improved from its previous Inadequate rating. Staff numbers, cleanliness, privacy and people's experience of care had improved. However, some risk assessments and care records were incomplete or out of date. Some medicines were not used safely, and the home's checks had not consistently found or addressed problems.
The overall rating is Requires Improvement. Safe and Well-led were rated Requires Improvement, while Caring was rated Good. The home had been in Special Measures, but it was no longer in Special Measures after this inspection. The report says the home remained in breach of Regulations 12 and 17.
Kind and respectful care
People said staff were kind and caring. Inspectors saw staff respect privacy and dignity, including knocking before entering rooms.
“People told us they felt the staff were kind and caring.” from the report
Enough staff
Inspectors found enough staff available to support people and respond to call bells. Recruitment checks were completed before staff started work.
“There were enough staff on the units to support people safely.” from the report
Cleaner environment
Infection control had improved. Units, bedrooms and bathrooms were cleaner and there was enough cleaning equipment.
“Units were clean and tidy and there was enough cleaning equipment and products available to ensure a high standard of infection control was maintained.” from the report
Improvement since the last inspection
The rating improved from Inadequate to Requires Improvement. The home also improved its handling of privacy, staffing and infection control, and was no longer in Special Measures.
“During this inspection the provider demonstrated that some improvements have been made.” from the report
Risk assessments and safe care
seriousSome assessments did not explain how to manage choking, weight loss or other risks. Some people on specialised diets were not always given food at the right consistency, and environmental hazards were found.
“People were exposed to risk of harm as some of their risk assessments and records were either not reflective of people's current needs or contained insufficient detail to help guide staff with how to support them safely.” from the report
Medicines given when needed
seriousSome medicines used during emotional distress were given without enough information about alternatives or a clear reason being recorded. The report says this was a breach of Regulation 12.
“Medication was not always being managed safely.” from the report
Weak management checks
seriousAudits, records and incident reviews did not consistently identify problems or show what action was needed. This continued to put people at risk and was a breach of Regulation 17.
“Despite some level of improvement, governance systems, oversight and records were still not robust which put people at risk of harm.” from the report
Environmental hazards
seriousInspectors found an open sluice room door, broken furniture and a large gap in one person's bed that could have caused entrapment. The manager acted when these concerns were raised.
“one person had a large gap in their bed, between the bedrail and the bedframe, which was large enough for them to become entrapped.” from the report
- 01What has changed in the risk assessments for people at risk of choking, weight loss or falls?
- 02How do you check that specialised diets are prepared at the correct consistency every time?
- 03How do you record and review medicines given when needed for emotional distress?
- 04What checks now make sure incidents, accidents and risks are identified and acted on promptly?
- 05What action has been taken to prevent further environmental risks, such as unsafe bed gaps or unsecured cleaning products?
This was a focused inspection of Safe, Caring and Well-led, including infection control and a previous Regulation 12 warning notice; the other key question ratings were carried forward from the last inspection. This explanation was written from the published report of 1 June 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.
Every inspection of Stonedale Lodge Care Home
7 rated inspections over 6 years: the service has slipped, from Requires improvement to Inadequate.
- June 2024Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2023Requires improvementup from InadequateSafe: Requires improvementCaring: GoodWell-led: Requires improvement
- September 2022Inadequatedown from Requires improvementSafe: InadequateCaring: Requires improvementWell-led: Inadequate
- October 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvement
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementCaring: GoodWell-led: Requires improvement
- December 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2017
Registered with the Care Quality Commission on 30 November 2017.
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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