Stonedale Lodge 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.

At our last assessment we rated this key question inadequate. At this assessment the rating has remained the same. 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 provider was previously in breach of the legal regulation in relation to governance. Not enough improvements were found at this assessment, and the provider remained in breach of this regulation.

This service scored 29 (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. For example, the provider did not always promote a positive and inclusive culture through learning following events or through formal supervisions with staff about their performance, training and development. Staff were uncertain about the future of the service. Their comments included, “Managers have not told us anything, we hear most stuff from families” and “Heard things through the grapevine."

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. For example, at the time of this assessment the manager appointed had not applied to CQC to assess their ability to become the registered manager of the home. We were not assured the provider and leaders demonstrated capability due to continuous breaches of legal regulations relating to people’s safety, leadership and governance. The provider and managers at all levels did not demonstrate a positive culture of compassion and inclusiveness. Staff felt uninformed about planned changes to the service which they said impacted on their wellbeing.

The provider did not foster a positive culture where people felt they could speak up and their voice would be heard. For example, there were limited opportunities for staff to speak up through regular team meetings and the use of surveys. Some staff members told us they didn’t speak up to senior managers as they believed they would not be listened to. One staff member told us, “I don’t see the point as they don’t listen” and another told us, “It’s a waste of time."

The provider did not always value inclusion in their workforce. Staff told us they did not always feel included in decisions about the home, and they did not feel fully informed about future plans. Records showed supervisions with staff were not regularly undertaken which did not support or promote the well-being of the staff team.

The provider told us they did arrange staff meetings to include staff in the running of the home; however, they told us these were not well attended by staff. The provider told us they have strengthened their processes to update staff by providing minutes of staff meetings following the inspection.

The provider employed a diverse staff group with a wide range of backgrounds and experiences.
 

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. For example, there had been continuous changes to management at all levels within the home impacting on the effectiveness of governance and leadership. The registered manager in post at the time of the previous assessment resigned from their role shortly after the assessment was completed. The providers had comprehensive governance framework; however, they were not operated effectively. The providers governance systems and processes continuously failed to assess, monitor, and improve the quality and safety of the service. Overall, audits were not completed at the required frequency as set out by the provider, and when completed, they failed to identify, mitigate risk and bring about improvements. This included clinical audits, IPC audits, financial audits, care plan audits and health safety audits.

We were not always assured audits were completed by suitably competent and trained staff with the right skills and competence. People’s care records were not always maintained. There were gaps in monitoring records indicating people had not received the care they needed at the right time. This included positional changes, personal care, food and drink and continence care. Sections of some peoples’ care plans had not been completed to reflect their current needs and/or updated to reflect changes in their needs.

This was a continued a breach of Regulation 17.

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. For example, the provider failed to act upon recommendations set by other stakeholders including the local authority (LA) following quality monitoring visits by the team. Recommendations set by the LA were not actioned to ensure people received safe and effective care to meet their needs. There was a lack of collaborative working with healthcare partners to ensure people received safe and effective care to meet their needs. People lacked opportunities to participate in meaningful activities and events in the local community.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. For example, there was a lack of continuous learning and improvement across the service. An analysis of safety events had not always taken place with the goal of improving future incident management and preventing recurrences. Following the last assessment the provider assured us improvements had been made, however, during this assessment we identified continuous concerns and new concerns. The providers current service improvement plan developed on 31 March 2025 listed multiple areas with actions for improvement identified at the last CQC assessment. There was little evidence to show the required improvements had been made, all but 1 of the actions remained in progress.