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 at this assessment, and the provider remained in breach of this regulation.

This service scored 32 (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 shared vision, strategy and culture, based on transparency, equity, equality and human rights, diversity and inclusion, engagement. For example, there had been further changes in leadership since the last inspection. Frequent changes and inconsistencies in management had resulted in a lack of clear direction, which continued to negatively influence the service’s culture and overall stability. Although the provider had recruited an external consultancy to support improvements in governance, this had not led to sustained improvements across all areas of care provision.

Staff had undertaken workplace culture training, indicating the provider was attempting to address longstanding cultural issues within the service. However, the culture among the staff team remained predominantly negative, and staff reported low morale.

The provider did not have inclusive and stable leadership at all levels. Leaders did not consistently demonstrate a clear understanding of the context in which they delivered care or embody the culture and values needed to support a positive workforce environment. For example, there was no registered manager in place. The manager in post at the last inspection had left, and an interim manager had been appointed. This was the fourth manager since November 2024, following several previous changes over the past 5 years. Continued breaches of legal regulations indicated ongoing concerns regarding leadership capability. Inconsistent leadership had weakened governance arrangements and contributed to a lack of sustained improvement. Despite the involvement of an external consultant, repeated concerns continued across several fundamental areas, and it remained unclear whether the provider’s systems and processes were sufficiently robust to drive, embed and maintain positive change.

Staff told us the frequent managerial changes left them feeling confused and unsettled. They reported receiving mixed messages and not being kept informed about developments within the service or plans for the future of the home. Comments included, “Managers come and go and tell you different things; nothing changes” and “We are left in the dark. We don’t feel we matter; it’s like they don’t care.”

The provider did not foster a positive culture where staff felt able to speak up and be heard. For example, staff told us they did not feel their feedback led to action, as concerns they raised, particularly about staffing levels and work pressures remained unresolved. Although staff received training in whistleblowing practices and the frequency of supervisions and team meetings had improved, providing more opportunities to share concerns, these were not experienced as effective. Staff reported they did not feel listened to or their views contributed to meaningful change within the service.

The provider did not always value inclusion within the workforce. For example, staff did not consistently feel inclusion was actively promoted or embedded across the service. Staff reported not feeling valued or included in decisions about the home, which left them uncertain about their future. A member of staff said, “We come up with ideas, but they just don’t listen” and another said, “Show no interest in what we have to say.”

However, the staff team represented a range of different faiths and cultures, contributing to a diverse workforce.

The provider did not have clear responsibilities, roles or systems of accountability in place, and governance arrangements were not effective. Leaders did not consistently act on the best information available about risk, performance and outcomes, and information was not always shared appropriately. For example, governance systems failed to reliably identify, monitor or address risks to people’s health and safety. Accident and incident records were often incomplete or contained gaps, limiting the reliability of analysis and reducing opportunities for learning. Incidents did not always trigger a review of people’s risk assessments, even when there was a clear change in risk level. Daily walkaround checks were undertaken inconsistently and did not always identify or address environmental concerns. Care planning records were not well maintained and contained widespread inconsistencies, which increased the risk of unsafe care. Care plan audits had not been effective in identifying the concerns inspectors found during this and previous inspections. Where provider audits had identified issues, actions were not completed in a timely way, and several audits contained multiple overdue actions, further increasing risks to people.

The lack of provider and managerial oversight resulted in continuous breaches of regulation. This was despite assurances an external consultancy was supporting the provider to improve governance arrangements; however, shortfalls in this area persisted and improvements had not been embedded or sustained.

The provider did not always demonstrate a clear understanding of their duty to collaborate and work in partnership to ensure services operated seamlessly for people. For example, although some information and learning was shared with partners, this was inconsistent. Communication with external stakeholders, including the local authority, was not always timely, and there were delays in providing important information about people. A family member told us they had requested to speak with a manager about their relative’s care, but no one had responded.

However, the provider had taken some steps to improve involvement with people and their families, including holding meetings and issuing newsletters to share updates about the service. Multidisciplinary team (MDT) meetings took place each week, bringing together health and social care professionals to review people’s needs, share information and support coordinated care.

The provider did not always demonstrate a sustained focus on continuous learning, innovation or improvement across the organisation or within the local system. For example, although some improvements had been made, progress had been slow and inconsistent. Across multiple inspections, we found a lack of continuous improvement and repeated breaches of regulation relating to people’s safety, leadership and governance. Improvements made since the last assessment were not fully embedded or consistently effective, and we were not assured lessons had been learned following previous breaches of legal requirements.

The provider had not shared the CQC draft report from the previous assessment with the managers responsible for quality assurance and service improvement. This limited the opportunity for those in key roles to understand identified concerns and take timely action to address them.