Stambridge Meadows Care 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 that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service under a new provider. This key question has been rated 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 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 registered manager described a clear vision for the service, focused on recognising people as individuals and supporting them to live their best lives. They also explained they were promoting greater engagement with people and the development of a more open safeguarding culture where staff felt confident to raise concerns. All staff we spoke with described a positive culture at the service.

Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The registered manager had been formally registered in post since 17 February 2026. The registered manager was supported by a deputy manager. The registered manager told us they felt well supported by the nominated individual and had regular contact with them. They said the nominated individual had been supportive of the improvements already implemented and those the registered manager had planned for the future.

Relatives and staff told us they had observed improvements in recent months, with relatives reporting increased confidence in the service. Feedback included, “The service has improved recently. The new management has helped. There have been a few meetings for residents’ families recently, and the manager’s door is always open.” Another relative added, “[Registered manager’s name] is the new manager and there’s been a marked improvement. I have more confidence in the home now.”
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt supported by the management team and all staff we spoke with said they found the registered manager to be approachable and felt able to raise concerns with them if they had any. One person told us, “We have 121’s, we can raise if we have any concerns or issues. I’m given time by managers to discuss concerns.”

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. The registered manager had a good understanding of the Equality Act. The provider employed a diverse staff team including different ethnic backgrounds and genders. The service had equality and diversity policies in place and promoted an inclusive and fair culture through training, staff had all received training in relation to Equality, Diversity and Inclusion.

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.
Governance systems were not effective in identifying or ensuring care consistently reflected people’s assessed needs or records were always accurate, complete, and up to date. Risk assessments, including those relating to individuals and the environment, were not consistently followed or monitored, and this lack of oversight had not been identified. As a result, people were exposed to avoidable risks. There was not always effective oversight systems to monitor and maintain people’s safety and wellbeing.
 

The provider worked in partnership with external medical and social professionals and services, such as GPs and the speech and language team, to support people’s health needs. However, they had not consistently followed appropriate specialist advice in relation to all risks relating to the management of legionella and water safety.

The provider’s approach to continuous learning, improvement and innovation was not consistently embedded across the service. The registered manager had identified several pre-existing issues in the service and action plans had been developed to address these areas. The management team were able to demonstrate that some identified areas for improvements were being progressed, with some actions already completed. For example, actions such as purchasing new equipment and delivering training to staff. However, during the assessment we identified concerns which had not been identified through the services own governance systems. This showed opportunities for learning and service improvement were sometimes missed and further work was needed to ensure concerns were identified promptly and improvements sustained.