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

The governance systems and processes operated by the provider failed to effectively assess, monitor and improve the quality and safety of the service. There was no registered manager in post, an interim manager had been appointed to oversee the day-to-day management of the service. Some family members had not met the manager and did not know their name. Throughout this assessment we made multiple requests for records to help us assess the effectiveness of the providers governance systems and processes. However, we did not receive all the records we requested, and many were duplicated and others did not cover the time period we set out. The providers audits and checks were not effective in identifying or addressing concerns we found during this assessment, some which were outstanding from our previous inspection in December 2023. We found continuous concerns and other concerns. A comprehensive review of the service was completed by the senior management team in June 2024 and they set actions for multiple items identified as requiring improvement. At the time of this assessment many items remained outstanding past the completion dates set. Actions plans were not always put in place where other checks identified areas for improvement. There was a lack of information recorded about accidents and incidents which occurred and no evidence to show they were analysed or of any lessons learnt. Safeguarding records lacked details of incidents and immediate action taken to protect people from further risk of abuse. Safeguarding concerns were not always referred onto the relevant agency for investigation leaving people vulnerable to further risk of abuse. Staff supervision and appraisal processes were not always followed to ensure staff had the opportunity to discuss in confidence any matters relating to their work or to review their performance. There was a lack of evidence to show the views about the quality and safety were sought from people, staff and family members.

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.

Staff told us there were few opportunities to make suggestions and when they raised issues, they did not always feel listened to. A staff member told us they don’t bother raising issues, because no one listens. Staff told us there had been a lot of inconsistencies in the management of the home which impacted on the overall staff morale. A member of staff told us, “Things keep changing it depends on which manager we have, it’s gets confusing.” Staff told us team and supervision meetings had not been regular.

Managers told us there were processes in place to include and engage staff such as staff meetings, supervision and appraisal meetings, satisfaction questionnaires, however, we were not provided with any evidence to support this.

Staff feedback was mixed, some staff told us leaders were visible whilst others told us they were not. Their comments included, “Yes, I do see [Manager’s Name] on the unit. I do feel I could approach the managers at any time” and “Occasionally see them but not very often.”

It was not always evident processes ensured managers understood the context in which care and treatment embodied the culture of the workforce. People did not always receive the care and support in line with their care plans. For example, we saw multiple examples of daily records which did not accurately evidence the care and support people received to fully minimise risks to their health, safety and well-being. Meal charts did not always evidence People who were on modified diets, such as fortified diets, meal charts did not evidence fortified meals/drinks had been offered or consumed. Meal charts for people who were prescribed to take their food at a certain consistency (to help minimise the risk of choking) did not always record the level or consistency of food they had consumed. Food intake records were not always completed for a person who was on a diabetic diet This put the person at risk of not having their diabetes properly managed and monitored.

The inaccuracies in peoples’ care records had not been identified and addressed by leaders.

Staff feedback was mixed with some telling us they had spoken up with confidence and felt listened to whilst others told us they were less confident as when they had spoken up in the past, they felt their concerns were ignored. Staff comments included, “I have no problem voicing my opinion” and “I’ve told the managers many times we are struggling as there’s not enough staff but it’s still the same. I don’t say anything anymore, nothing gets done.”

There was a whistleblowing policy in place, but there was no evidence it was used effectively. The providers supervision and appraisal processes were not used effectively to enable staff the opportunity to discuss any matters such as concerns they had. We were told regular staff meetings occurred with written records available of what was discussed and agreed; however, the records were not provided to us when requested to enable us to review staff involvement and their contributions. There was no evidence staff and people’s feedback had been gathered through the use of surveys; we were provided with just 2 surveys completed by family members that were completed in June 2023.

Feedback from staff confirmed action was taken to help prevent any disparities in the experience of staff with protected equality characteristics. One member of staff told us, “Yes, I feel we are looked after here.”

Staff had received training in relation to equality, diversity, and human rights. The providers supervision and appraisal processes were not always used effectively to ensure staff had the opportunity to share with their manager any confidential information about any additional support they may require in the workplace.

Managers and staff told us they understood their roles and responsibilities and had clear lines of responsibility and accountability. However, we found they failed to act on information about risk to ensure positive outcomes for people.

There was no registered manager in post. A new manager was appointed after October 2023 but left their post following the last inspection. An interim manager was appointed until another permanent manager was recruited in September 2024 and they left in October 2024. A member of the senior management team was appointed to oversee the day-to-day management of the service whilst the provider was recruiting for a permanent manager. There was a full-time deputy manager working and a team of senior staff appointed to different areas within the service with specific managerial responsibilities. The provider had comprehensive systems and processes for assessing and monitoring the services quality and safety, however, they were not used effectively in identifying risk and bringing about improvements. Checks and audits were not always completed and those that were showed limited evidence of actions taken to make the required improvements. Accident, incident and safeguarding records did not provide details of the actual event, and they had not been analysed to ensure appropriate action was taken to mitigate further risk. Senior managers with responsibilities for oversight of specific areas provided regular oversight on behalf of the provider however, there was little evidence of change to drive and sustain improvements since the last inspection in December 2023. We found multiple examples of records completed for care and support people did not receive in line with their care plans, this included hygiene charts and food and fluid intake charts.

We received mixed feedback from people and family members about the support from other health and social care professionals. One person told us, “I see my doctor when I need to.” A family member told us, “I’ve waited a long time for them to sort out an appointment for [relative] and am still waiting.” A family member told us they were disappointed they had not been informed about the need for their relative to move out of the service to another care service.

Managers and staff told us they worked in partnership with others such as GPs, community nursing teams and local authorities. We did however, observe examples when managers and staff failed to follow and obtain advice from other professionals.

Other health and social care professionals where not always confident referrals to other services were made in a timely way for people. For example, when there was a deterioration in a person’s skin and when prescribed medicines were not given. A high number of safeguarding referrals had been raised by other health and social care professionals and were being investigated. Partner agencies including the local authority and community nursing teams were providing ongoing support to help improve outcomes for people.

Processes were not always effective in helping to ensure people received the best possible outcome with regards to their care and support. Although people’s care plans evidenced how staff involved external partners to help ensure people received the right care and support to meet their needs in a holistic way, staff did not always follow external professionals' advice. For example, we saw how for one person who was to be given their medicines covertly, the advice given by the pharmacy had not been properly adopted into the care plan for staff to follow.

Staff told us they were unfamiliar with the services quality assurance systems. A member of staff said, “The managers and seniors see to all that, we don’t get involved.” Staff told us they were unaware of any formal process in place for sharing any improvements or lessons learnt. A staff member said, “Whoever is in charge on the day tells us about any changes.”

Improvement plans along with actions plans were developed for areas identified as requiring improvement including areas for improvement identified during our last inspection in December 2023. Records we reviewed showed actions had not been completed within the required timescales set and we found continuing concerns and other concerns. A comprehensive review of the service completed by senior managers in June 2024 identified an overall rating of ‘Major improvement needed.’ The review listed a wide range of items which required improvement and timescales for completion. The action plan attached to the review showed many of the actions had not been completed within the required timescale and remained outstanding despite completion dates ranging from June 2024 to October 2024. There were processes in place for reporting and recording events such as accidents and incidents, however, there was no evidence to show what learning had taken place and how it was shared across the staff team to encourage improvement.