Stewton House Nursing Home

Inspectors saw staff treating people with kindness and dignity. Relatives were mainly positive about how staff treated people.

“During our inspection, we observed staff treating people with kindness and dignity.” from the report

People were offered food choices, suitable support and plenty of drinks. Kitchen staff had information about people's dietary needs.

“We observed lunch being served during our inspection and saw people were given a range of options, the food looked and smelt appetising and people had appropriate support.” from the report

People were offered activities and could contribute to activity planning. Visits were supported to reduce social isolation.

“During our inspection, we saw people being offered opportunities to engage in activities.” from the report

Care plans recorded people's communication, preferences and some end-of-life wishes. The home also worked with relatives and medical professionals on emergency care decisions.

“There was evidence the provider had worked with people and their relatives to incorporate people's views and wishes into an end of life care plan.” from the report

Staff received supervision and training in areas including safeguarding, moving and positioning, and fire safety. Some staff were supported with further qualifications.

“Staff received supervision. Records we reviewed showed staff had received supervision in line with the provider's policy of carrying these out twice per year.” from the report

Some incidents involving medicine errors, injuries and allegations of abuse were not referred to the local safeguarding team or CQC. This meant they were not independently investigated.

“Safeguarding referrals were not always completed.” from the report

Four bed rail entrapment incidents had occurred, but protective bumpers were not always fitted correctly. Window restrictors, unsecured furniture and access to hazardous items also created risks.

“People were at risk of entrapment in bed rails.” from the report

Some creams and liquid medicines were not dated when opened. Records also showed significant medicine errors, including wrong-person and missed medicines, without consistent investigation or follow-up.

“People did not always receive their medicines safely.” from the report

Managers did not consistently investigate, sign off or learn from incidents. Audits did not identify several safety and care record problems before the inspection.

“The provider's governance systems were not consistently effective.” from the report

Some staff did not wear masks correctly. A first-floor kitchen was not effectively cleaned, with unlabelled opened food and dirty equipment and flooring.

“Staff were not always using personal protective equipment (PPE) effectively and safely.” from the report

Staff and relatives said shifts were often short-staffed. Agency staff who were unfamiliar with the home did not always have a documented induction.

“A member of staff raised concerns they frequently found shifts were understaffed.” from the report