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 changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider demonstrated a clear shared direction and culture that placed people at the centre of their care. Conversations with the registered manager showed they shared these values and was committed to ensuring people were treated with dignity and respect, recognised as individuals, and encouraged to maintain their independence by doing as much as they were able for themselves.

These values were embedded in practice. We saw evidence people were supported to personalise and decorate their bedrooms and were involved in decisions about the decoration of communal areas.

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.

Staff we spoke with told us they felt supported in their roles and said training was sufficient to equip them with the knowledge and skills required to meet people’s individual needs. A review of the training matrix confirmed training provided was appropriate and tailored to people’s health needs, including areas such as catheter care, stoma care and diabetes awareness.

We saw evidence of regular staff supervisions and team meetings, demonstrating effective systems were in place to provide ongoing guidance, oversight and support to staff in their roles.

Staff treated people as individuals, people using the service and their relatives told us staff knew them well, including their personal preferences. Everyone we spoke with said they knew the manager. One person told us, “The manager is always around; I find her welcoming, she will often just come in for a chat.”

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

The service promoted an open and transparent culture where people and staff felt able to raise concerns. There was a whistleblowing policy in place, which clearly outlined the steps staff should take if they needed to report concerns. This supported a culture of openness and accountability.

There were regular team and resident meetings in place, providing opportunities for people to share their views, raise concerns, and contribute to decisions about the service. Several people told us they attended the monthly residents’ meetings and felt they were beneficial. One person told us, “I go to residents’ meetings every month, I think they are useful, I feel they listen to me.”

A complaints policy was in place and was available in an easy read format to support accessibility. People told us they were aware of the complaints process and knew who to speak to if they needed to raise a concern. There were no complaints for us to review at the time of the assessment. However, we saw several written compliments from people and their relatives, reflecting positive experiences of the service.

People we spoke with knew who the registered manager was and felt they were approachable and available. This helped to ensure people felt confident to speak up and raise any concerns or feedback they may have.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a positive and inclusive culture within the staff team. Staff spoke positively about the support they received from management and described an open environment where they felt comfortable raising concerns or discussing their needs. One staff member told us, “I have no issue with going to (the registered manager) about anything; if they can help, they will.” Another staff member said, “I feel listened to. Recently I needed to change my shift pattern due to personal issues, and (the registered manager) accommodated this.”

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 service had systems in place to support governance and oversight. Accidents, incidents and near misses were reviewed at the time they occurred, and we saw evidence care plans and risk assessments were updated promptly to reflect changes in people’s needs. This helped to reduce the risk of repeat incidents and showed a responsive approach to individual risk management. However, while accidents, incidents and near misses were reviewed, the analysis was not consistently detailed enough to identify themes or trends across the service. This limited the provider’s ability to clearly evidence learning from incidents and to demonstrate how this learning was used to drive continuous service‑wide improvement.

Similar limitations were identified within spot‑check audits, where opportunities for learning and oversight were not fully maximised. For example, call bell audits did not include checks of staff response times, and there was no clear system in place to routinely monitor sensor mats. This meant there was a risk that equipment used to support people’s safety was not consistently checked or maintained.

We found evidence of oversight of audits within the service and a structured approach to quality assurance. The registered manager monitored audit activity and was receptive to feedback. During the assessment, the registered manager took appropriate action in response to the on‑site feedback regarding specific audits and checks, demonstrating openness and a willingness to improve.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

We saw evidence the provider was working in partnership with the local authority quality assurance team and had taken appropriate steps to implement improvements as advised. We found the service was proactive in communicating with external healthcare professionals regarding people’s care, ensuring their health needs were supported through a multi-disciplinary approach.

People told us they were supported to access their local community and take part in activities which were important to them, including attending their local church.

The provider did not consistently demonstrate a focus on continuous learning, improvement, and innovation across the organisation and wider system. They did not always take proactive steps to explore creative or innovative approaches to ensure equality of experience, outcomes, and quality of life for people.

Learning and improvement at the service were primarily reactive rather than proactive. The provider’s quality assurance and governance systems were not consistently effective in identifying areas for improvement at an early stage. Issues were often identified following external input or review, rather than through effective internal monitoring. This meant opportunities to identify risks, drive improvement, and embed learning were not always recognised or acted upon in a timely way.

The provider demonstrated a willingness to learn and improve by engaging with the Local Authority and responding to external feedback. We saw evidence the service acted when concerns were raised and implemented recommended improvements. For example, the provider responded to feedback from CQC during this assessment by introducing sensor mat checks and strengthening PRN medicines protocols to improve safety.