Stamford House Care Home

There was a breach of regulation as people did not always receive safe care and treatment, and there was not always sufficient oversight of aspects of the safety and quality of the service. People’s care plans were not always accurate, detailed and clear in relation to people’s risks and changes in their needs meaning that staff did not always have the relevant information on how to safely support people. Accident and incident forms were being completed however they required further analysis of trends. The level of analysis was inconsistent and it was not always clear that risk had been appropriately mitigated.

Improvements were needed to ensure good oversight of recruitment processes and that staffing levels and deployment were reflective of the need of people. Further oversight was needed to ensure timely action was taken to improve the environment to ensure it was meeting the needs of the people living at the service.

At this assessment, the medication cycle had just begun. The information relating to the medicines people required had not all been correctly transferred in line with the new cycle. Where people required medication ‘as required’, directions for staff around the administration were not always available. The recording of thickeners was not being consistently recorded at the time it was given to people.

There was a breach of regulation as the provider lacked oversight and whilst systems for checks and audits were in place they were not completed sufficiently robustly to ensure improvements were driven. We found shortfalls in how oversight was maintained in areas such as staffing levels and recruitment, as well as the environment and management of individual risk. Staff felt supported by the management team and there were opportunities to share ideas in meetings and raise concerns where needed.