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

This service scored 61 (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.

The provider had a statement of purpose. However, leaders and staff did not have a clear understanding of the visions and values of the service, or what processes were in place to achieve them.

We received mixed feedback from people and relatives about how well the provider informed and included them decisions about the home and how it was run. Some people were happy with the communication from the provider, whereas some stated the provider did not keep them informed at all. Generally, people thought the provider could improve their communication to promote choice and control in people’s care.

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 had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People and staff spoke positively about the registered manager. One person said, “Whenever you need the manager, she's there.” Staff told us they felt the registered manager had the appropriate knowledge and skills to lead.

We observed the leaders engaging positively with people throughout the inspection. For example, we observed the registered manager supporting a person with personal care and assisting another person to make a phone call to a family member.

The registered manager told us they felt supported by the area manager, and the provider was approachable.

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 procedures which was understood by staff. Staff told us they felt comfortable to raise concerns and felt assured that appropriate action would be taken. However, they were confident in the process to escalate concerns if they felt they had not been heard or no action was taken.

The registered manager held an open-door policy to encourage people, staff, and visitors to approach leaders directly with questions, concerns, ideas, or feedback. An open-door policy can help to build trust and transparency within the service.

The provider worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they felt supported by leaders. A staff member said, “I’ve worked here for many years, I wouldn’t still be here if I didn’t [feel supported]”.

The provider held welfare meetings with staff if an individual error or incident occurred. The registered manager told us the aim of the meeting was “to not place blame on anyone, but to address the issue and support the staff member to learn”. The meeting could also be requested at any time by a staff member themself if required.

Regular team meetings were held where staff had the opportunity to voice ideas of improvement. The provider also gathered staff feedback through an annual survey and within supervisions. Staff told us they felt included in understanding what improvements needed to be made to the service.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s auditing systems were not always robust. The leaders completed a range of checks and audits to monitor and to help drive improvements. However, although auditing systems had identified some of the issues we found during this inspection, they had not resolved them. Similarly, where issues had been resolved, there was a lack of clear documentation to confirm this.

We found most auditing systems did not assess the quality or comprehensiveness of the area being assessed, instead they focused 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. While care plan audits contained an “overall summary” where areas such as “documentation quality” and “accuracy completeness” were given a rating from 1-5, there was no guidance available for staff as to what the scoring meant or how to accurately and consistently score each area based on the information within the care plan.

However, the provider had a management planner in place which detailed the daily, weekly, monthly, and annual tasks needed to be completed by the staff and leaders. The registered manager displayed an improved awareness and oversight of these tasks following the previous inspection.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always engage with people, communities and partners to share learning with each other that results in continuous improvements to the service.

The provider did not have any links to the local community, and people told us there was little activities or stimulation happening within the home. Links with the local community can have a significant impact on a person’s wellbeing by encouraging social interaction and inclusion, as well as maintaining a person’s identity by helping them feel connected to their community.

However, we found evidence the provider collaborated with healthcare partners to ensure people had access to appropriate care and treatment.

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.

The provider failed to address some of the concerns and areas for improvement identified during our previous assessments around safe medication management. We found the service was in continued breach in some areas and were not assured that learning and improvement had been fully embedded throughout the whole service.

The provider had not effectively used their own auditing processes and procedures as the basis for making service improvements. As a result, there were shortfalls in the service that they were not aware of until they were brought to their attention during this inspection and by the local authority.

However, the provider had improvement plans underway to enhance and upgrade the environment. The provider had already replaced the flooring and carpeting throughout most of the home, had a new shower room installed, and had further plans to make improvements elsewhere in the home.