Stoneyford Care Home

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

During our assessment of this key question, we found concerns around dignity and respect which resulted in a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. While people told us most staff were kind and caring, they felt staff were not always available to support them in a person-centred way or to respond to their immediate needs. Staff and people were not always supported with regular opportunities to give feedback or gain support. The management team told us they were actively recruiting an activity co-ordinator however people told us they lacked opportunities to participate in activities relevant to them and were not supported to access the community. Many people we spoke with used the word ‘bored’ to describe their experience.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People gave mixed feedback about being supported with kindness, compassion and dignity. Most people told us staff were kind and caring but were always busy. People gave examples of asking staff for drinks or support to go to the toilet but having to wait extended periods for support or not receiving the support at all. One person said, “I asked [staff] for a cup of tea the other day and they said yes, it never did arrive. It’s not unusual for that to happen, they are always so busy.” Another person said, “Some staff really will go above and beyond and they are great, others seem to spend time in groups together and not with us.”

Staff we spoke with could describe how to treat someone with kindness, dignity and respect however due to time constraints they were not always able to spend enough time with people to ensure this need was fully met. One staff member said, “I always try and treat people with kindness, I know how important something as simple as sitting and having a chat with someone can brighten their day but at times, we can be so busy helping people and responding to call bells we don't always get the chance.” We discussed with the compliance manager the concerns people had raised and the observations we had seen on the assessment. They acknowledged there was a failing and that staff had previously raised concerns to them about certain staff members and their practices. The compliance manager stated the management team had been investigating these practices; however, we were not shown any evidence to support this such as incident reports or competency checks.

A professional we spoke with told us they had been approached by a person living at the home for support as they felt the home was not listening to their concerns. The person said, “[Resident] approached me and asked for help to communicate with the management team, and they were not listening to [Name’s] concerns. They told me they were ignored whenever they voiced their opinion. I spoke with the manager, but they were very defensive.”

We observed a staff member supporting someone to eat their lunchtime meal. The staff member did not engage with the person, they did not explain what food they were eating or ask if they were ready for any more before placing the food into their mouth. The staff member also used their hand to push the person’s head back before placing food into their mouth. This action was repeated consistently during the whole meal. This is not an appropriate method of manual handling or person-centred support and placed the person at risk of harm. We conducted a short follow up visit to observe the immediate changes the provider and management team had put in place following our assessment. Staff were now supporting people appropriately during the lunchtime meal.

People told us they were not treated as individuals and were not supported to do the things they liked or wanted to do. One person said, “I would love to get out into the community, just to the local shop every now and then but it doesn’t happen. They have a tuck shop here but everything in the cabinet is out of date.” A relative told us, “We asked if we could bring my [relative’s] own bedding in to make them feel more at home, it was only here a few days, and everything had disappeared.”

Some staff were knowledgeable about people’s likes and dislikes and tried to support people with their choices and wishes. For example, we saw evidence of a staff member going above and beyond. They had recently adopted a new kitten and people had expressed a wish to meet the animal. The staff member attended on their day off to bring the kitten in to meet people. We spoke with staff who told us they knew that certain people wanted to go out and about in the community but confirmed there was not enough staff on shift to support to do this while keeping everyone safe.

Some people’s care plans stated for various reasons that they were to only be supported by female staff members. We observed those people being supported by male staff members consistently throughout our assessment. This meant their personal choices were not respected.

Although the provider had policies in place, people were not always treated as individuals or included in decisions about their care. For example, one person had not been consulted regarding a decision made relating to their care package. The compliance manager had written to the person’s relative and communicated the decision and requested they inform the person living at the home. This demonstrated that the management team did not treat people as individuals and acted against best practice in regards the Mental Capacity Act as the person had full capacity. We discussed this with the compliance manager who acknowledged the failing and stated it was error in judgement.

People told us they were not always supported to have independence, choice and control. Several people we spoke with commented that staff decided what time people should go to bed. One person said, “It’s ok for me as I am fully mobile but others who are not don’t get a choice about when they go to bed it’s done to suit staff.” Another person said, “It usually starts about 7pm, if you watch, one by one staff come and get people and take them to their rooms for bed, that way everyone is in bed by about 10pm. Even if they don’t go to bed, they are made to put their pyjamas on. I think it’s just easier for staff.” Other people we spoke with told us that activities were lacking within the home. One person said, “I used to love to knit, I would like to do that again as an activity or even just get some wool so I can do it on my own.” Another person said, “It would be fantastic to have a games night where we played cards and dominoes, the only option we get after 3pm is the TV.”

During the mealtime service we observed people being given glasses of orange squash. One person commented, “I'm sick of drinking this, I’m not three years old. I would love a glass of wine with my meal.” We spoke with staff who confirmed there was no other option of beverage available other than hot drinks and that this was normal practice. We observed staff encouraging people to go to bed while we were on the assessment. We heard staff telling people, “It’s getting late” and “You really should go and rest.” We spoke with a staff member who stated that staffing levels reduced after 10pm. They said, “After 10pm there is only 3 of us so if someone needs 2 staff to go to bed it can leave us short staffed on the floor to support people.”

People were not always supported appropriately to be independent and have choice and control. We observed one person in the communal lounge who was walking with purpose doing laps of the area. Staff followed the person despite the person requesting to be left alone, however the staff member continued to follow the person which caused them to experience agitation and frustration. We reviewed the person’s care plan which stated they enjoyed walking in communal areas and were free to do so as they were not at risk of falls. This meant the person’s choice was not supported or respected.

Care plans we reviewed did contain information on how people wished to spend their time and what activities they enjoyed. However, we could not find any evidence within the daily care records to show people were supported to undertake any of these activities. The management team acknowledged the lack of activities and stated they were currently recruiting staff to the activities co-ordinator position to ensure consistency. The management team also stated they would be implementing further spot checks to ensure improvements were made and people’s choices were supported in the evening and during their bedtime routines.

We received mixed feedback from people regarding how their immediate needs were met. People told us they were confident staff would come in a timely manner if they pressed their emergency call buzzer. One person said, “They [staff] are really good at night, someone always comes if I press my buzzer.” However, people stated they struggled to get staff attention whilst in communal areas and this repeatedly led to delays in having immediate needs such as toileting and obtaining support for periods of crisis such as someone displaying distress from frustration or agitation.

During the assessment one person was unresponsive and required medical attention and observation until a doctor arrived. We observed this person being drag lifted into a chair and they remained unresponsive. We approached staff to ask whether further observations had been undertaken to ensure the person was stable following the inappropriate manual handling procedure and they confirmed further observations had not been done. We informed the manager immediately and requested this was completed which resulted in emergency medical assistance being sought for the person. However, we were not assured or confident this would have been completed without the assessment team’s intervention.

We did not always observe staff responding to people’s immediate needs. For example, we observed people requesting support from staff with things such as personal care and toileting and having to wait more than 30 minutes for support. We saw a person request a cup of tea from a staff member whilst sat in the conservatory, the staff member proceeded to ask other people if they wanted a drink as well, however they only offered this choice to people who were able to respond verbally. Other people present were not offered and did not receive a drink.

Staff told us their concerns were not always listened to or acted upon by the provider or management team. Staff we spoke with were not aware of the recent registered manager’s resignation or the new management structure. One staff member said, “Oh I didn’t know [registered manager] had actually left, I know someone called [Name] has been coming in, but I have no idea what their position is.” Another staff member said, “It must be six months since I had a supervision, there can be issues with getting annual leave and my pay isn’t always right.”

Records reviewed, such as supervision and competency records, showed staff did not receive regular opportunities to provide feedback or gain support. We saw written communication between staff and management that supported the feedback above and that we reported on in safe that evidenced how staff struggled to secure annual leave. This meant people and staff did not experience a culture that normalised wellbeing through inclusivity, active listening, and open conversations that would enable staff to do their job well and feel well.