Stoneleigh House

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 that 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 remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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

This service scored 54 (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 which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

People and relatives provided mixed feedback about how well the provider communicated and involved them in the home and how it was run. A relative told us, “Feedback could be better. I only found out after overhearing you and a staff member talking, they [people] all have a key worker. I’ve just asked and [name] is my [relative’s] key worker. I’ve never been introduced to her.”

People could not recall attending any resident meetings or being asked for their views about the care provided or the home overall. One person stated, “I've not been asked about my views and I'm not aware of any residents’ meeting or questionnaires.” A relative told us, “They do have questionnaires. You are asked questions like, ‘Would you wish to be involved in training’? However, even though I’ve answered yes, nothing has ever come of this. There are no meetings for relatives though.”

We noted a named member of staff was responsible for facilitating resident meetings. From reviewing meeting records, it was not clear how often meetings were held or how the meeting was run. There was no agenda or attendance list, with each set of minutes consisting of a list of each person within the home, and next to their name had been written one or two words, such as ‘settled’, ‘happy’ or ‘settled and content’. There was no indication of what topics had been discussed or that people’s views had been sought. This may account for why people told us no meetings were held.

The registered manager confirmed no relative meetings were held, instead individual meetings were completed with people and/or their relative to review the care plan, during which they were asked a number of questions. This included if people / relatives would like to be involved in staff interviews, take part in staff training, if they were happy with the care provided and if they had any suggestions or recommendations. Whilst the seeking of this information was positive, and showed how the provider wanted to include people and relatives, there was no evidence to show any action had been taken to address or implement anything discussed during these meetings.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders led with integrity, openness and honesty.

People and relatives spoke positively about the home and how it was run. One person stated, “I know that [name] is the manager, and she is a lovely lady.” Another person said, “I know [manager’s name] well. She’s helpful, she listens and tries her best for you. The manager will sort things out for any of us.”

Staff also spoke positively about the registered manager. One staff member told us, “I feel confident raising concerns with [registered manager] and that they would be looked into, they are very approachable. Another stated, “[Registered manager] is approachable. I feel the home is well-run. Things have definitely improved since they took over managing the home.”

We noted a number of examples of how the registered manager had been supportive of staff either in aiding their development, though signing up for and encouraging them to complete external qualifications or in being flexible with shifts and working hours, to help staff manage personal issues and family situations outside of work.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a whistleblowing policy and procedure in place, which staff were aware of. Staff spoke with stated they knew how to raise concerns and who to go to if they felt they had not been heard, or no action was taken. Comments included, “Yes, there is a policy downstairs in the office. I would go to the manager first, then the area manager, then go higher up” and “Yes, they do [have a procedure in place]. If there was anything I was concerned about, I would go to the manager, if they didn’t listen I’d go to the next step, which would be speak to the area manager. If they didn’t listen, I would go further up.”

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.

We asked the provider what systems and processes were in place to support staff wellbeing. The registered manager told us ad-hoc welfare meetings were completed as and when requested, however, aside from this, there was no specific staff wellbeing initiatives in place.

Staff’s views and opinions had been sought through questionnaires. However, surveys were either not dated, or dated consistently, which meant we were unable to confirm how often questionnaires had been circulated and how old feedback received was. We saw no evidence during our site visits that any analysis had been completed of staff responses, and actions generated to address any concerns raised. We fed this back to the provider, who sent us a brief analysis document for review after the site visits had been completed. We did not see this document in any of the files we viewed, nor were made aware of its availability when providing verbal feedback at the end of our first day on site.

Staff told us they felt supported and treated with dignity and respect.

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.

We found the providers audit and governance process was not robust. The home’s audit file contained a list of what audits were completed, however, a number of these were not actual audits but daily or weekly tasks, such as staff holiday recording, rota completion and food ordering. For areas where actual audits were due to be completed, these were not located within the audit file, which instead contained documents on which the registered manager and/or other management team members signed to confirm the relevant checks, audit or monitoring process had been completed.

The majority of monitoring tasks and audits were assigned to named staff. However, we found there was a lack of formal audit documents for staff to use, which set out the standards expected, so they had something to benchmark against when completing their checks. We also noted the majority of audits were not set up to assess the content, quality or comprehensiveness of the area being assessed, instead they focussed more on whether something had been done or was in place. For example, care plan audits looked at whether care records contained the correct documents and sections, rather than assessing the quality of information, to ensure it made sense, was sufficiently detailed and not contradictory.

We also found there was a lack of clarity and guidance on what staff were checking, why and what actions should be taken if any issues were noted. For example, one staff member was tasked with completing a weight audit each month. All the audit documented contained was a list of people with either ‘fine’ or ‘okay’ written next to each person’s name. It was not documented what the purpose of the audit was, or what fine / okay meant. Another staff member audited oral care. The audit form they completed just stated ‘all rooms checked and okay.’ Again, there was no information about what the audit covered, was it that people’s teeth had been cleaned, they had a toothbrush and toothpaste, or something else?

As already mentioned, the process for checking care plans was not robust. The care plan and risk assessment audit just stated care plan audits had been completed, with no detail about what, if anything had been identified. Our review of care plans identified a number of issues, including a lack of detail and contradictory information. For example, one person’s care plan summary document stated they used an airflow bed (there is no such thing), and to ensure their mat was plugged in. There was no other reference to this mat within the care plan, to explain what it was and what it was for. Their care plan contained conflicting information about the support they required with personal care, stating they could do so independently in one section but required support of a staff member in another. Another person was reported to mobilise independently in one section, but required supervision of a staff member when mobilising in another. A third person’s care plan stated they could not always express when they were in pain. However, there was no guidance for staff on the signs and symptoms to look for, should the person not be able to tell them. This may have impacted on the timeliness with which they received pain relief. None of these issues had been picked up during monthly care plan reviews completed by the provider.

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.

We were provided with limited examples of how the provider worked in partnership with other organisations and/or the local community, to enhance people’s experiences. The registered manager shared a flyer which advertised an Easter party at a local rugby club, which we were told some people had attended. A photograph of some people sat at a table within a large hall, was also shared, which we assumed was people attending this event.

The registered manager also told us in early 2024, the home had been involved in the ‘blended roles project.’ This was a project which aimed to upskill staff to complete tasks which might otherwise be done by an allied health professional. This upskilling would be achieved by practical training sessions, followed by competency checks carried out by health professionals involved in the project. The 2 areas covered by the project were frailty falls. We asked the registered manager for feedback on the success of this project. They told us around 50% of staff at the time attended sessions and a few staff were competency assessed to check equipment, such as the ferrules on waling frames. However, there were no formal records available to confirm attendance, what had been learned and what specific tasks staff were now upskilled to complete.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

We found there to be a lack of action or improvement plans to show what issues had been identified though governance processes and what was being done to address these. There were no action plans within the home’s audit file, and none were noted within the file where staff’s checks and audits were stored. We raised this with the provider during feedback and was subsequently provided with an updated action plan template the registered manager planned to use moving forwards, and an action plan dated 2025. However, the action plan consisted of issues highlighted by CQC as part of the assessment process, rather than anything identified by the provider through their own internal processes, both at home and provider level.

As previously reported in the safe key question, we saw no examples of learning from accidents, incidents or safeguarding concerns, nor any systems in place to support this process. We noted, the new action plan template also did not contain a section for lessons learned, so it was unclear where this information would be documented in future.