Stoneacre Lodge Residential Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

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 have a clear shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. We identified the culture in the care home focussed on what worked for members of staff rather than on providing person-centred care which enabled people to have choice and control over their lives. There were some common practices which were institutional, for example, set days for people to have baths or showers. The provider and the management team had not recognised the impact on people caused by delivery of care which was not person-centred.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity and openness. Leaders were not effective and not able to lead and manage the service effectively. The registered manager told us they carried out daily walkarounds, but these had failed to identify what we found on inspection. There had been a failure by the management team to identify and act where care and support could be improved or practice challenged. People who lived in the care home were not aware of who the registered manager was. One person told us, "I don’t know who the manager is. The way this place is run leaves little room for enjoyment.”

The provider did not always foster a positive culture where people felt they could speak up and their voice would be heard. One person told us, "I have never complained. I don’t think it would make any difference.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. There was limited information about how the provider engaged with the staff team. Where a meeting had taken place, there was a record of feedback from staff which identified staff pressures, the need for training on the electronic care planning system and suggestions about how handover meetings could be run more effectively. However, there was no evidence of these suggestions being listened to or actioned. A common theme in the feedback from members of staff was the number and availability of staff which reflected our observations about staff being task-focussed and people who did not receive timely support.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Following the previous inspection of the service on 7 January 2025 there had been some improvements to some monitoring processes, specifically environment checks, but governance and management of the service was still failing overall. Audits and reviews had failed to identify poor delivery of person-centred care and care plans had not been fully updated or moved over to electronic systems. There was a consistently disorganised approach to paperwork and processes which failed to identify areas which required immediate improvement and action. This was the third assessment since 2020 where the provider had failed to achieve a rating of good for this key question.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. There was limited evidence of engagement with people and their families through meetings where their feedback could be listened to and actioned to make improvements care and people’s daily experience.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. The lack of effective systems and management meant there was no drive to improve the safety and quality of person-centred care and support being delivered. People continued to have poor experiences of care and there was a lack of action to improve outcomes for people. There was limited evidence of learning and improvement following the last assessment of the service.