Working at Stonesby House LTD

Risk plans and care plans are not up to date for every resident, medicine records have conflicting details like wrong insulin doses, and infection control has gaps like poor mop storage.

the registered manager told us they were still working on these, so they had not been reviewed for everyone living at the service... There was conflicting information on the Medication Administration Records (MAR), the PRN (as needed) protocols and the grab sheets. For example, one person's grab sheet showed incorrect levels of a person's insulin... the storage and sterilisation programme for mop heads did not follow best practice.

Quality audits and checks keep missing problems, so managers do not spot all the issues that need fixing.

these [internal audits] needed to be strengthened because they were not always effective at identifying areas where improvement was needed. For example, medicines audits had not been effective at recognising the conflicting information we found in medicines records.

Activities take place but staff interactions are often task-focused with little person-centred engagement, making the role feel routine.

we found that many staff interactions were still task focused and lacked a person-centred approach. For example, at lunch time there was no other interactions from staff except to give people their meals and then take away their empty plates.