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 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, and the provider remained in breach of this regulation.

This service scored 36 (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 or culture that promoted transparency, equity, equality, human rights, diversity, inclusion and engagement. For example, management roles and responsibilities were not clearly defined. When we requested information from members of the management team, there were inconsistencies about who held oversight and responsibility for key systems and processes, including safeguarding and staff training.

The culture within the staff teams remained largely negative. Staff told us there had been no positive changes since the last inspection, and they were unable to describe the provider’s vision and values for the service. Staff comments included, “No idea” and “Not really sure.”

Leaders did not have the skills, knowledge, experience and credibility to lead the service effectively, nor did they consistently demonstrate integrity, openness or honesty in their approach. For example, there was no registered manager in post; the previous registered manager left in May 2025. A new manager was appointed in July 2025 and submitted an application to CQC in September 2025 to become the registered manager. However, the managers application was incomplete and returned to them for further information. The manager was unaware of this as they had not checked their mail.

Although we identified some improvements since our last visit, there continued to be repeated 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 or inclusiveness. Staff told us they felt uninformed about planned changes to the service, which they said had a negative impact on their wellbeing.

The provider did not foster a positive culture in which people felt able to speak up and be heard. For example, although staff told us they felt confident to raise concerns, many said they were reluctant to do so because they felt nothing would change. Multiple staff reported they had raised concerns about staffing levels, but no improvements had been made.

Ancillary staff told us they felt unsupported, explaining they no longer had a departmental manager. One member of staff told us their previous line manager had left some time ago and had not been replaced, meaning they no longer had access to supervisions or team meetings where they could share their views and wellbeing.

Although the frequency of one‑to‑one supervisions had improved for some staff, they did not feel these were meaningful or effective. Staff comments included, “They are a waste of time, no one listens” and “I keep asking the same things, still no answers.”

The provider did not always value inclusion within the workforce. For example, staff told us they felt uninformed, anxious and uncertain about their future. Comments included, “Units shutting and not feeling we have been kept informed, think they don’t tell us because we would leave,” “We have meetings, but they keep telling us the same thing” and “I’m worried about my job, I just need to know what’s going to happen.”

However, the staff employed represented a range of different backgrounds, faiths and cultures, and equal opportunities monitoring formed part of the provider’s recruitment processes.

The provider did not have clear responsibilities, roles, systems of accountability or effective governance arrangements. Leaders did not consistently act on the best information available about risk, performance and outcomes. For example, there had been continuous changes to the management and leadership of the home, which had negatively affected the effectiveness and stability of governance. Staff told us this had undermined confidence and continuity within the service. One member of staff said, “We have a bad history of managers leaving, not getting comfortable with this one,” while another commented, “Managers keep coming and going.”

The provider’s governance systems and processes remained inconsistent and did not demonstrate sustained progress. Systems to robustly assess, monitor and improve the quality and safety of the service continued to be ineffective. Events such as accidents, incidents and safeguarding referrals lacked appropriate scrutiny and oversight to ensure risks were identified and mitigated in a timely way. There was a lack of robust managerial oversight of staffing to ensure safe staffing levels were maintained at all times or staff had the appropriate skills to safely meet people’s needs.

People’s care records were not always maintained to an acceptable standard. Care plans did not consistently reflect people’s current or changing needs, and there were gaps in monitoring records, indicating people had not always received the care they needed at the right time.

The provider did not always understand or fulfil their duty to collaborate and work in partnership with others to ensure services worked seamlessly for people. They did not demonstrate effective collaboration to drive improvement. For example, the provider failed to act on actions set by other stakeholders, including the local authority, following quality monitoring visits undertaken at the home. The local authority had identified ongoing concerns relating to the planning and monitoring of people’s care, the environment, and infection prevention and control. These concerns remained outstanding at the time of our visit.

However, managers attended weekly multidisciplinary team (MDT) meetings alongside other health and social care professionals. These meetings were used to discuss people's needs and coordinate their care.

The provider did not always demonstrate a focus on continuous learning, innovation or improvement across the organisation or within the local system. Although some improvements had been made since our last assessment, these were not fully embedded or effective. We were not assured lessons had been learned following previous breaches of legal regulations.

There continued to be inconsistencies in the completion of people’s care records, accident and incident records, safeguarding documentation and the records used to communicate people’s care needs and individual risks. This lack of consistent and accurate documentation meant the provider was unable to evidence sustained improvement or effective learning from previous failings.