Stoneacre Lodge Residential 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 requires improvement. At this assessment the rating has remained requires improvement. This meant the service 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 the governance of the service.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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. They did not always understand the challenges and the needs of people and their communities. The management team had failed to implement improved systems to deliver a positive experience and good quality of life for people. Areas for improvement found at previous inspections had not been addressed.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. There was poor organisation of paperwork and systems to maintain an overview of the service. Limited oversight and management reviews meant the service was not always safe, person-centred or well led.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager had responded to complaints about the service. Processes were in place to help ensure concerns could be raised by people and staff and leaders investigated appropriately.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. The provider had processes in place to ensure staff were treated in an inclusive way. Processes were in place which helped to protect the rights of staff under the Equality Act. Risk assessments and any reasonable adjustments measures were utilised if required. 

The service 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. The provider did not carry out regular reviews of the service audits to ensure care was delivered safely. Monitoring checks and audits were not carried out consistently by the registered manager which meant the service was not safe and care was not delivered safely and in line with people’s care plans. Governance processes were not effective. This is a breach of regulation 17 good governance and we asked the provider to take action.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Resident and relative meetings did take place but the last meetings took place in 2023. A survey for families was completed in April 2024 but the outcomes from the meeting were not displayed in a place where people could see them easily. A family member told us, “Yes, I have [received a questionnaire]. The last one was about 6 months ago.”

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. There was not an effective learning culture in the care home. People’s views and feedback was not always valued as an opportunity to improve the quality of care and support. Staff team meetings had identified areas for improvement but there was no evidence any actions had been put in place.