Date of Assessment: 17 and 18 September 2025 Stubblefields House is a care home providing accommodation and personal care for up to 10 people. They are registered to provide support to people with a range of different needs, including people with a learning disability and / or autistic people. At the time of the assessment there were 8 people living at Stubblefields House. This assessment was to follow up on actions from the last inspection in January 2022. The provider was previously in breaches of legal regulations relating to person-centred care planning, risk management, management and oversight, and staffing. Improvements were found at this inspection and the provider is no longer in breach of any regulation. However, sustained improvement is required to the management and oversight of the service. At the last inspection we also made recommendations about best practice in medicines and to review their systems for recording and monitoring accidents and incidents. Improvements had been made in these areas at this inspection. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, dignity, choices, independence and good access to local communities that most people take for granted. This provider was able to demonstrate how they were meeting the underpinning principles of ‘Right support, right care, right culture’. Stubblefields House demonstrated a strong commitment to person-centred care, safety, and continuous improvement. Safety incidents were appropriately investigated and reported, with managers showing a proactive attitude towards learning and development. People were supported effectively during transitions into and out of the service, and safeguarding practices were robust, including timely DoLS submissions being completed when required. Risk management was generally well organised, through discussions with individuals, and the service promoted independence and provided emotional support. However, documentation inconsistencies, such as missing or unclear risk assessments, highlighted areas for improvement. The physical environment was well-maintained and personalised and wholly reflected the involvement of people living at the service in its decoration. Recruitment practices were thorough, although inconsistencies in staff files suggested a need for an improvement in record-keeping. Staff were well-trained and supported, and the home maintained high standards of cleanliness. Medication administration was safe, but some discrepancies between records required attention. Care planning was comprehensive and personalised. However, we found documentation could be more consistent and clearly dated. Nutritional and health needs were met through innovative and supportive approaches. Social engagement was actively promoted, and people were encouraged and supported to pursue individual goals and interests. Consent and advocacy were appropriately addressed, with staff fostering respectful and compassionate relationships. Communication needs were well-documented and met, and people were empowered to make choices about their daily lives. Staff responsiveness and prioritisation of people’s comfort were evident. Staff wellbeing was supported through supervision and recognition initiatives. The service collaborated effectively with partner organisations and ensured equitable access to support and opportunities. Future planning, including end-of-life care, was considered. Governance structures included regular policy reviews and open communication channels with people, relatives and staff. Managers were accessible and engaged. They promoted a culture of openness and feedback. While some quality assurance processes were in place, these required further embedding to ensure consistency and oversight, particularly in care records. Stubblefields House delivered a caring, inclusive, and responsive environment, with a clear focus on individual needs and have made significant improvements since the last inspection. However, further work to address documentation consistency and quality assurance gaps would support a sustained improvement in the effectiveness and reliability of the care provided.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-960790876.
Stubblefields House deteriorated from Good to Requires Improvement following a focused inspection in January 2022, with breaches of Regulations 9, 12, 17 and 18 identified in relation to person-centred care, safe care and treatment, governance, and staffing. Key concerns included insufficient staffing levels, ineffective infection control measures, unmitigated environmental and health risks, outdated care plans, and a failure of governance systems to identify and address these issues.
Concerns (11)
criticalInfection control: “Donning and doffing stations were not appropriately placed. They were in a high traffic area and not in separate areas to reduce the risk of contamination.”
criticalStaffing levels: “There were insufficient staff employed to run the service safely. The registered manager and acting manager were consistently on shift whilst also carrying out their own roles.”
criticalGovernance: “Systems in place were not effective. They had not always identified the areas of concern we found at this inspection.”
criticalPerson-centred care: “Blanket decisions were made as a service rather than on an individualised basis meaning people did not always receive care centred around them.”
criticalStaff training: “Staff had not received training to support people with their health conditions, such as epilepsy.”
moderateCare planning: “Care plans had not been reviewed to ensure people's hobbies, interests and social needs were met during the pandemic.”
moderateStaff competency: “Competency assessments were not carried out to ensure staff had the appropriate skills for their role.”
moderateMedication management: “One person had medication that was discontinued remained in their medication cabinet, and their prescribed creams had no opening or discard date.”
moderateRecord keeping: “Records were not always fully completed or accurate. This included people's health records, supervision records, induction records and recruitment records.”
moderateConsent / capacity: “People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests.”
minorIncident learning: “Accident reports for the incidents that had occurred did not contain sufficient detail.”
Strengths
· People and relatives shared positive feedback about the service and the management team.
· Staff had received safeguarding training and felt confident to report any abuse.
· The management team were receptive to feedback and took action during the inspection to address identified issues.
· Care plans were in place to support people's communication needs and documents were available in accessible formats.
· The provider was actively recruiting additional staff.
Quality-Statement breakdown (15)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
responsive: Planning personalised care to ensure people have choice and controlRequires improvement
responsive: Meeting people's communication needsGood
Stubblefields House received an overall rating of Requires Improvement at its October 2016 inspection, with ongoing concerns around visitor access controls, staff induction, supervision frequency, and record keeping despite improvements since the previous 2015 inspection. Caring and responsive practice were rated Good, reflecting strong person-centred support, dignified care and positive relationships between staff and the people who used the service.
Concerns (5)
moderateSafeguarding: “when we arrived at the service we were let in by a person who used the service. There were no staff in the main part of the building to ensure any visitors were safe to be in the building”
moderateStaff training: “The induction for new staff was not in-depth, but did cover the basics of health and safety and working in the home. Work was on-going to embed more robust induction processes in the service.”
moderateSupervision / appraisal: “We looked at the supervision files for three members of staff and found that these were taking place, but not on a regular basis. We also noted that staff appraisals were not being completed on a yearly basis.”
moderateGovernance: “some record keeping in the service such as staff induction, supervision and appraisals needed to be documented on a regular basis. Work was on-going with this and was being monitored by the local authority”
minorRecord keeping: “handwritten entries on the MAR charts did not have two staff signatures to show that what had been recorded by the staff matched the instructions on the pharmacy label”
Strengths
· People told us that they felt safe living at the home and staff had a good knowledge of how to keep people safe from harm.
· Improvements had been made to the management of medicines; people received these on time and as prescribed.
· Robust recruitment and selection processes were in place including DBS checks, references and interviews.
· Care plans were person centred, individualised and written in clear print and pictorial formats people could understand.
· People received compassionate care from kind staff who knew their needs and preferences and respected their privacy and dignity.
Stubblefields House was rated Requires improvement overall following an unannounced inspection on 8 May 2015, with two regulatory breaches found: unsafe medicines management (Regulation 12) and ineffective quality assurance systems (Regulation 17). Caring and responsive practice was rated Good, supported by kind staff and personalised care plans, but significant gaps in staff training, night staffing, supervision, appraisal and governance required urgent attention.
Concerns (8)
criticalMedication management: “staff were giving people their medicines, but not always signing on the medicine administration record (MAR) to show that it had been administered.”
criticalGovernance: “the registered provider's quality monitoring system was ineffective and had not been used to measure or ensure the safety of people who used the service and staff.”
moderateStaff training: “No staff had completed training on the Mental Capacity Act 2005 (MCA)...No staff had completed specialist training on learning disabilities.”
moderateStaffing levels: “there was no waking member of night staff even though some people who used the service had epilepsy and there was a risk they could have a seizure during the night.”
moderateSupervision / appraisal: “no staff appraisals had been done for some time...the care manager...personal supervision was not taking place.”
moderateRecord keeping: “audits did not always contain any analysis of the information gathered or an action plan to show what action was being taken to improve the service.”
minorCommunication with families: “Staff had limited skills in the use of Makaton to aid communication with people who used the service.”
minorCare planning: “there was no end of life information captured such as what people's wishes and choices would be in the event of their death.”
Strengths
· People were protected from harm or abuse with effective safeguarding systems; all staff completed SOVA training and understood their responsibilities.
· Care plans were individualised and person-centred, reviewed monthly with involvement from the person using the service.
· Staff demonstrated kind, patient and respectful care; people reported feeling safe, happy and treated with dignity.
· People had access to a range of health care professionals including GPs, specialist nurses, dentists and opticians, with patient passports in place.
· Risk assessments were regularly updated and guided staff appropriately; premises were safe and well maintained.
Quality-Statement breakdown (18)
safe: Medicines managementRequires improvement
safe: SafeguardingGood
safe: Staffing levelsRequires improvement
safe: RecruitmentRequires improvement
safe: Risk assessment and managementGood
effective: Staff training and competencyRequires improvement
effective: Supervision and appraisalRequires improvement
Stubblefields House received a Good rating across all five key questions at its November 2017 inspection, with inspectors finding a warm, family-orientated environment in which people with learning disabilities felt safe, respected, and well supported. No regulatory breaches or areas requiring improvement were identified.
Strengths
· People felt safe with staff, with positive feedback including 'I am always safe, I tell staff where I am going and when I'll be back'
· Medicines managed safely using a bio dose system with individual locked cabinets and correctly completed MARs
· Staff recruited safely with robust DBS checks and two references per file
· Strong person-centred culture described as family-like: 'It's not a service as you described it's a family'
· Effective quality assurance system with regular audits covering all areas of the service
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Working in partnership with othersRequires improvement
effective: Mental Capacity Act / DoLS
Good
effective: Nutrition and hydrationGood
caring: Person-centred and compassionate careGood
caring: Privacy and dignityGood
caring: Involvement in care decisionsGood
responsive: Care planning and personalisationGood
responsive: Activities and community accessGood
responsive: Complaints handlingGood
well-led: Quality assurance and governanceRequires improvement
well-led: Leadership and cultureGood
well-led: Record keepingRequires improvement
effective: Health care access and support
Good
effective: Nutrition and hydrationGood
caring: Dignity, respect and person-centred interactionsGood
caring: Involvement in care decisionsGood
responsive: Care planning and personalisationGood
responsive: Activities and community engagementGood
responsive: Complaints handlingGood
well-led: Quality assurance and governanceRequires improvement
well-led: Leadership and management cultureGood
well-led: Record keeping and auditRequires improvement