1 June 2012
During an inspection in response to concerns
At the time of this inspection there were three men living at Stone Cottage and we spoke with, or observed, all of them during our visit. The men had varying levels of communication abilities. One man told us he was "very well" and liked living at Stone Cottage. He talked about a job in the house that he had particular responsibility for and was involved in when we arrived. We spoke with the other two men and they responded verbally but it was not possible to hold detailed conversations with them because of their communication needs. We observed that there were positive interactions between the men who lived in the home and the staff on duty who were quick to respond to people's needs or requests for assistance. We also saw that the staff treated people with respect and ensured their dignity and privacy were upheld when providing personal care.
We spoke with the unregistered manager, two members of staff, and a newly appointed member of the operational management team who arrived at the home during our visit. The staff team demonstrated a good knowledge of the needs of the men who lived in the home. They were able to tell us about different types of abuse, and what they needed to do to keep people safe. They told us what they would do if they suspected that abuse or any type of poor practice had occurred within the home. However the staff had not recognised that a behavioural management plan in place for one person was an abusive practice and inappropriate use of physical intervention until they were told it was by a healthcare professional. We spoke to a healthcare professional who confirmed that staff in the home were no longer using these guidelines to manage the person's particular behaviour.
We looked at the systems in the home to manage people's medicines and found it had not changed since our last inspection. Therefore people were at risk of receiving the wrong medicines due to unsafe practice followed by the staff in the home. We also found that the staff team did not know what some of the medicines were for or why they were prescribed in tablet or liquid form. This showed that the training staff had received related to the management of medicines was not suitable as it had not led them to change the unsafe practice operating in the home.