Stoneacre Lodge Residential Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence the provider met people’s needs. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant services were not planned or delivered in ways which met people’s needs.

The service was in breach of legal regulation in relation to person-centred care.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs. At our previous inspection on 7 January 2025, we identified a breach of regulation in relation to person-centred care. There had not been any improvement in the service and care was still not person-centred. Generic risk assessments indicated a lack of person-centred care and an institutional approach to bathing and showering, managing violence and aggression, and use of the stair lift. The main door in to and out of the lounge was still locked via a keypad and people did not have the freedom to move about their care home when they wanted. This was not the least restrictive way of managing any identified risks to people. Members of staff were task focussed and not able to provide person-centred care and meet people’s needs in a timely way. We observed 1 person who requested to be supported to move from the dining room to the lounge after their breakfast. It took over 45 minutes, and numerous requests from the person, for this to be achieved because staff were focussed on tasks rather than individual’s needs. People’s care plans did not always reflect people's individual needs and preferences or suggest ways which ensured their preferences and needs were met. There were 2 lunchtime sittings in the dining room where people ate their main meal of the day. However, people had were not given any choice about which sitting they wanted to attend. The decision around who ate at which sitting was made by members of staff. When we asked people about how they felt, 1 person told us, "I think the atmosphere is awful, this is not a nice place. I am hoping to leave.”

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity. People were not offered choice about their care and support and care was not always joined up. There were limited links with the local community, however, 1 person independently attended a local community centre for group-based activities. Feedback from members of staff told us there were not always sufficient numbers on duty to provide joined up care. When we asked people about their experiences of joined up care and activities they told us, “I’m bored. There is nothing going on here.” and “We used to do bingo, but we don’t do that anymore which is a shame. [Members of staff] don’t do any of the things I would like to do. The staff used to have more time to chat or play cards but that doesn’t happen now either.”

The provider did not always supply appropriate, accurate and up-to-date information in formats tailored to individual needs. One person told us how they missed a hospital appointment because the provider did not share the information with them, "I was furious once. The hospital sent me an appointment but [the provider] didn’t tell me until the day I was due to go. It was my letter addressed to me and [the provider] didn’t give it to me or even bother to tell me. It was my letter. I also missed an appointment because [the provider] messed it up. I was really angry but there hasn’t been a problem since.”

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not involve people in decisions about their care or tell them what had changed as a result. Engagement with people and their families was limited. Where people, who lived in the care home, had been asked about their views, there was no analysis of the feedback and no actions put in place. It was unclear how people’s feedback and views were used and what had changed as a result. A family member told us, "We had a meeting about a year ago and talked about more activities and doing the garden up but none of that has happened.”

The provider did not always make sure people could access the care, support and treatment they needed when they needed it. People told us they only had access to baths and showers once a week. People told us they would prefer to have more frequent baths. A relative told us, “[Family member] used to get a bath once a week but now she is hoisted she has a bed bath.” Another relative told us, “My [family member] came in on Monday and they haven’t had a bath yet [4 days after admission to the care home].”

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. People's care was not tailored to their individual needs and there was evidence of institutional approaches to care and support in place, for example specific days for showers, members of staff determining when people ate their main meal and a lack of stimulating engagement activities.  

People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life. There were risk assessments and information in people's care plans about end-of-life care. However, when people were on end-of-life care pathways, their care plans did not reflect any personal touches or attention to detail which ensured care in people’s final days was person-centred and dignified.