CQC report explained · a residential care home
What the CQC found at St Stephen's Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, December 2022
Rated Requires Improvement; inspectors found kind care and enough staff, but medicines, risk management and care planning were not always safe or up to date.
Inspectors visited on 20 and 21 September 2022. They spoke with people, relatives, staff and a health professional, observed care and checked care records, medicine records, safety checks, staff training and complaints systems.
The main safety concerns were medicines records, risks linked to people's health and mobility, and some environmental issues. Medicine records had unexplained gaps and one person's tablet was left in their room without staff taking action. These issues placed people at risk of harm and breached Regulation 12.
Care was rated Good for Effective and Caring. People were supported with food, drinks, healthcare, choices, privacy and dignity, and were treated kindly. Safe, Responsive and Well-led were rated Requires Improvement because safety systems, care plans, activities and management checks were not consistently effective.
The home had a new manager and people, relatives and staff described recent improvements. However, there was no registered manager at the inspection, and CQC asked for an action plan and said it would continue to monitor the home.
Kind and respectful care
People described staff as kind and respectful. Inspectors saw staff showing empathy, supporting choices and promoting privacy, dignity and independence.
“People were positive about the relationships they had built with staff and described staff as kind.” from the report
Staffing and recruitment
Inspectors found enough staff at the visit, and people did not have to wait long for help. Recruitment checks were completed before new staff started.
“There were enough staff to care for people. We saw people did not have to wait long if they wanted support from staff.” from the report
Food, drink and health support
People were offered meal choices and support to eat and drink enough. Relatives and a health professional described improvements in people's health outcomes.
“You can see the outcomes; [people] have gained weight.” from the report
Support with communication and relationships
The home supported people to keep in touch with relatives and to practise their faith. Communication plans included tools such as pictorial cards, large print and translation.
“People were supported to keep in touch with others who were important to them.” from the report
Medicines and risk management
seriousMedicine records had unexplained gaps and inaccurate balances. Staff guidance about moving around the home and managing health conditions was not consistent, increasing the risk of harm.
“This placed people at risk of harm.” from the report
Care plans not kept current
needs fixingSome care plans were not updated promptly when people's mobility or other needs changed. They did not always give staff enough guidance about underlying health conditions.
“People's care plans did not always guide staff to provide the care they wanted.” from the report
Limited activities at some times
minorSome people said there were few activities in the evenings and at weekends. Activities could also make the dining area noisy and interrupt television viewing.
“Some people told us activities were not available during the evening, or at weekends.” from the report
Leadership and quality checks
needs fixingThe new manager was applying to register with CQC, but there was no registered manager at the inspection. New checks had not yet become reliable enough, and provider checks missed the medicines concerns.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01How are medicine administration records and running balances now checked for gaps or errors?
- 02How have care plans been updated to reflect changes in mobility and underlying health conditions?
- 03What repairs and environmental safety actions identified at the inspection have now been completed?
- 04What activities are available in the evenings and at weekends, and how are they matched to each person's interests?
- 05Is the manager now registered with CQC, and how are leadership and quality checks being kept consistent?
This inspection examined all five key questions, with particular attention to medicines, skin health, falls management and infection prevention; the previous comprehensive inspection was rated Good. This explanation was written from the published report of 17 December 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2021
Rated Good; inspectors found safe, effective and well-led care, with some changes in staffing and a delay at one mealtime.
This was a focused inspection on 10 and 11 November 2021. It followed concerns about management, staffing and falls risks. Inspectors spoke with people, relatives, staff and health professionals. They observed care and checked care records, medicines, recruitment, accidents, incidents, equipment and quality checks.
Inspectors found that people felt safe and that risks, medicines, staffing and infection control were being managed. Staff had suitable training and recruitment checks. People's needs, food choices, healthcare and consent were generally supported well.
There had been changes in the management and staff teams. Inspectors found that staff morale was improving, although staff views about management varied. There was a delay while people waited for lunch, but inspectors did not find that this harmed them.
The overall rating was Good. Safe improved from Requires Improvement to Good, while Effective and Well-led remained Good. Caring and Responsive were not inspected during this visit, so their previous ratings were used when calculating the overall rating.
Safer care
People and relatives told inspectors they felt safe. Staff understood safeguarding procedures and risks were assessed in ways that supported people's independence.
“People and their relatives told us they felt safe at the home.” from the report
Medicines
Inspectors found that medicines systems had improved and were being managed safely. Staff were trained and checked as competent before giving medicines.
“At this inspection, we found improvements had been made and sustained.” from the report
Skilled staff
Staff received induction and ongoing training. Inspectors found that staff had the skills and knowledge needed to support people.
“People were supported by a staff team who were provided with the training they required to meet people's diverse needs” from the report
Health and choices
People were supported to choose food and drinks, maintain their health and access healthcare. Staff sought consent and followed mental capacity requirements.
“People were supported to have choice and control over their lives and staff supported them in the least restrictive way possible” from the report
Quality oversight
The provider used regular audits and staff handovers to monitor care, risks and improvements. The manager worked with the regional manager to oversee quality and safety.
“The provider had quality assurance systems and processes in place, based upon an established audit schedule” from the report
Changes in the staff team
needs fixingThere had been changes in management and staffing, and agency staff were being used to cover shortages. Staff gave mixed views about management and some did not feel valued, although morale was improving.
“We received varied views from staff we spoke with about the management at the home including some staff not feeling valued.” from the report
Delay at lunchtime
minorInspectors saw people waiting at the dining tables before receiving their meals. They did not find evidence that the delay affected people, but they raised it with the manager.
“There was a delay with people sitting at the tables waiting to receive their meals.” from the report
Manager registration
minorThe home did not have a manager registered with CQC at the time. A manager had been appointed and their application was progressing.
“The service did not have a manager registered with the Care Quality Commission [CQC].” from the report
- 01What is the current staffing team, and how often are agency staff being used?
- 02What has been done to improve staff morale and make staff feel valued?
- 03How are falls risks being assessed and reviewed for my relative?
- 04How will people be kept safe while refurbishment work continues?
- 05What has been done to prevent delays when people are waiting for meals?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and previous comprehensive inspection ratings were carried forward. This explanation was written from the published report of 25 December 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of St Stephen's Care Home
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2021GoodSafe: GoodEffective: GoodWell-led: Good
- January 2021Inspected but not ratedSafe: Inspected but not rated
- March 2019GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017
Registered with the Care Quality Commission on 11 May 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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