CQC report explained · a residential care home
What the CQC found at Stonesby House LTD
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments and care plans were not always reviewed after changes or incidents. Medicines records were sometimes inconsistent, and infection control arrangements still needed improvement.
- Effective?
- Good
- This focused inspection did not assess the Effective key question.
- Caring?
- Good
- This focused inspection did not assess the Caring key question, although inspectors observed that some staff interactions remained task focused.
- Responsive?
- Good
- This focused inspection did not assess the Responsive key question. The report said care did not always promote independence, choice and inclusion.
- Well-led?
- Requires improvement
- Governance systems and audits had improved but did not reliably identify medicines, infection control, food, equipment and care planning problems.
What inspectors found, June 2021
Rated Requires Improvement; inspectors found improvements, but medicines, care records, infection control and quality checks were still not reliable.
This was an unannounced focused inspection over 29 April and 04 May 2021. Inspectors spoke with people, relatives, staff and managers. They reviewed care records, risk assessments, medicines information, staff files and quality checks.
The overall rating improved from Inadequate to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The home had enough staff, safer recruitment checks had improved, and safeguarding systems were stronger.
However, risk assessments and care plans were not updated for everyone. Medicines records contained conflicting information, some infection control arrangements needed improvement, and there was out-of-date food and first aid equipment. Quality checks had not reliably found these problems.
The home had been in Special Measures since 09 December 2020, but it was no longer in Special Measures after this inspection. The home remained in breach of Regulations 12 and 17, and CQC requested an action plan and further monitoring.
More staff available
Inspectors found enough staff to meet people's needs. Staffing assessments and records had improved.
“We found there were sufficient staff to meet people's needs.” from the report
Stronger safeguarding
Safeguarding systems and staff training had improved. Staff said they felt more confident raising concerns.
“Systems in place to safeguard people from avoidable harm had been reviewed and enhanced to ensure people were protected.” from the report
Improved recruitment
The home had improved recruitment checks, including references and Disclosure and Barring Service checks before new staff started.
“Disclosure and barring service (DBS) security checks and references were obtained before new staff started employment.” from the report
Better incident learning
A new system was used to analyse accidents and incidents and record actions taken.
“This ensured that lessons were learned, and improvements made to people's care.” from the report
Improved staff support
Training records were more organised, a training matrix had been created, and staff said they felt more supported.
“Staff told us they felt more supported.” from the report
Medicines records
seriousMedicines records contained conflicting information. There was also missing guidance for different pain relief and one missing tablet was found.
“There was conflicting information on the Medication Administration Records (MAR), the PRN (as needed) protocols and the grab sheets.” from the report
Care plans and risk assessments
seriousSome care plans and risk assessments had not been reviewed after people's needs changed or after accidents and incidents.
“We found that following an accident or incident they had not been reviewed or updated.” from the report
Infection control
needs fixingSome infection control arrangements needed improvement, including mop head storage, stained toilet areas, missing paper towels and open bins.
“Some improvements had been made to the infection control procedures in place, however we found some areas still needed to be addressed.” from the report
Food and first aid checks
needs fixingInspectors found out-of-date food, food without opening or freezing dates, and out-of-date items in the first aid kit.
“We found numerous items of food that were out of date.” from the report
Person-centred care
needs fixingSome staff interactions were mainly focused on tasks. Care did not always help people build skills, independence or achieve their goals.
“However, we found that some staff interactions were still task focused and lacked a person-centred approach.” from the report
Quality monitoring
needs fixingAudits and checks had improved but did not consistently identify problems that needed fixing.
“However, these were not always effective at identifying areas where improvement was needed.” from the report
- 01How will you make sure every person's care plan and risk assessment is updated when their needs change or after an incident?
- 02What checks now confirm that medicines records, PRN guidance and medicine stocks are correct?
- 03What has been done to fix the infection control issues found with mop heads, toilet areas, hand towels and bins?
- 04How do you check that food and first aid equipment are within date and properly labelled?
- 05How will you make sure care is person-centred and helps people develop skills, independence and choice?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings were not assessed in this report. This explanation was written from the published report of 9 June 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.
What inspectors found, April 2021
Rated Inadequate and placed in special measures; inspectors found serious risks in safety, staffing, infection control and management.
This was a focused inspection after concerns about staffing, infection control, training, the environment and leadership. Inspectors visited on five dates in October and November 2020. They spoke with people, relatives and staff, and checked care records, staff files, medicines, training and management records.
Inspectors found people were at risk of harm. Risk assessments and care plans did not give staff enough guidance when people became distressed. There were unsafe responses, including using a bicycle lock on fire doors. Staffing levels did not meet people's assessed needs, and some recruitment checks and training were incomplete.
There were also serious concerns about infection control, medicines, safeguarding and the condition of the home. Some incidents were not reported properly. Management checks did not identify or fix important problems, and staff said they did not feel supported to raise concerns.
The overall rating was Inadequate. Safe and Well-led were both rated Inadequate. The service was placed in special measures, meaning CQC said it would monitor the home and normally re-inspect within six months unless the provider's registration was cancelled.
Some urgent changes
After the first inspection day, the provider made some improvements to infection control, risk management and the environment.
“On the second day of our inspection we checked to see if the provider had taken urgent action to address the most serious risks outlined in this report and found that some improvements had been made to infection control and prevention, risk management and the environment.” from the report
Action plan and extra resources
The provider produced an action plan and deployed extra resources after inspectors raised the most serious risks.
“In response, the provider developed an action plan detailing actions taken and planned, to make improvements and reduce risk.” from the report
People at risk of harm
seriousCare plans and risk assessments did not give staff enough information to support people safely when they became distressed. Staff used unsafe strategies, including locking fire doors with a bicycle lock.
“There was a lack of effective training for staff to support people when they became distressed.” from the report
Safeguarding failures
seriousPotential abuse and assaults were not always reported to the right authorities. Incidents were not consistently reviewed so that care and safety could improve.
“Not all incidents and accidents had been reported to CQC or safeguarding.” from the report
Insufficient staffing
seriousStaffing numbers did not meet people's assessed support needs. On the inspection day, a person needing two-to-one support did not receive it.
“On the day of our visit there was a shortage of staff and the person who required 2-1 support did not receive the required support.” from the report
Poor infection control
seriousPPE and handwashing supplies were not readily available, procedures were not followed and inspectors found dirty equipment and serious damp in the home.
“Government guidance to protect people living in care homes during Covid 19 were not adhered to.” from the report
Medicines not safely managed
seriousThere were problems with medicine storage, expired opened items, staff training and incomplete or unclear medicines records. These issues could mean people did not receive medicines as prescribed.
“Systems in place to ensure the proper and safe management of medicines were not robust.” from the report
Weak leadership and oversight
seriousManagement checks failed to identify serious problems. Feedback and concerns were not acted on, and staff did not feel supported to speak up.
“There was a lack of effective quality assurance processes in place to monitor the quality and safety of the service.” from the report
- 01What staffing levels are now in place for people who need one-to-one or two-to-one support?
- 02What training have all staff completed for supporting people who become distressed, including positive behaviour support and any use of restraint?
- 03How are medicines now checked, stored and recorded, and how are staff assessed as competent to administer them?
- 04What changes have been made to infection control, PPE access, handwashing facilities, cleaning and damp or damaged areas?
- 05How are safeguarding incidents, complaints and staff concerns now reported, reviewed and used to improve care?
This was a focused inspection of Safe and Well-led, including infection prevention and control under Safe; the other question ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 2 April 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 Stonesby House LTD
6 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- June 2021Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- June 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Registered with the Care Quality Commission on 30 September 2013.
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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At least 100 live-in carers within about an hour of Leicester
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 £980 to £1,270 a week. 83 can care for a couple. 12 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
“Tino was the most wonderfully rounded, empathetic and intuitive person. He not only developed a great relationship with Neville but also had a great working relationship with our existing carer.”
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.