St Stephens Care Home

Updated 29 December 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 3 inspectors and a specialist nurse advisor.

Service and service type

St Stephen's Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. St Stephen's is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the start of our inspection there was a registered manager in post, subsequently the manager applied to de-register.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 9 people who used the service and 5 visiting relatives about their experience of the care provided. We spoke with 16 members of staff, including the operations director, deputy manager, nurses, care and ancillary staff.

We reviewed a range of records. This included 10 people's care records and several medication records. We looked at 7 staff files in relation to recruitment and staff training. A variety of records relating to the management of the service, including policies and procedures were reviewed. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who are unable talk with us.

Updated 29 December 2023

About the service

St Stephens Care Home is a care home providing personal and nursing care for up to 40 people across two units, one specialising in providing care to people living with dementia. At the time of the inspection there were 23 people living at the service.

People’s experience of using this service and what we found

Since our last inspection, the provider had made some improvements to the service, however other improvements had not been sustained and further improvements were required.

Whilst the provider had made changes to aspects of their governance systems, they did not have effective oversight to safely mitigate environmental risks, ensure the premises were maintained, ensure staff were always suitably deployed or had received appropriate induction training and supervision.

The provider had not ensured risks in relation to the environment were fully monitored and managed. This included the safe storage of items, security of the premises and aspects of fire safety. Not all the required health and safety checks had been undertaken. Feedback from people, staff and our observations indicated staff were not always suitably deployed.

Some improvements had been made, and systems were in place to protect people from abuse. Overall medicines were managed safely and systems were in place to help prevent the risk of infection.

The provider had not addressed all the issues we found at the last inspection. Aspects of the premises needed to be improved, including ensuring the service was dementia friendly and areas needed refurbishment. Some actions had been commenced, such as the installation of new flooring.

Managers had taken some action to provide supervision to staff and support them to undertake the required training and eLearning. However, we were not assured staff had always received appropriate induction training and supervision.

Staff had made improvements in relation to working with other agencies to support people to receive effective care. Overall, people and their relatives were positive about staff and told us they were knowledgeable and communicated well. However, further improvements were needed to ensure people’s individual needs were fully supported.

Overall, the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The provider had implemented an electronic recording system, however, whilst some improvements had been made to people’s care records, records relating to the care provided were not always complete and accurate.

The provider took several immediate actions during the inspection to address the issues raised and planned to make further changes to accelerate the required improvements.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 6 December 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

At our last inspection we recommended the provider set out a programme of environmental improvements and shared the progression with people using the service. At this inspection we found insufficient action had been taken to progress improvements. This service has been rated requires improvement or inadequate for the last 3 consecutive inspections.

Why we inspected

We received concerns in relation to staffing levels. As a result, we undertook a focused inspection to review the key questions of safe, effective, and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Stephens Care Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to staffing, the premises, safe management of risks and governance. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.