CQC report explained · a nursing home
What the CQC found at St Stephens Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2023
St Stephens Care Home is rated Requires Improvement; inspectors found ongoing risks with staffing, premises, training and management oversight.
This was an unannounced focused inspection after concerns about staffing. Inspectors visited on 09, 12, 13 and 17 October 2023. They spoke with people, relatives and staff, and checked care records, medicines records, staff files and management records.
The home had improved some areas, including medicines management, infection control and working with health professionals. People and relatives were generally positive about staff. However, inspectors found that staffing was not always sufficient, some safety checks and environmental risks were not properly managed, and some staff did not have complete induction, training or supervision.
The home remained rated Requires Improvement for Safe, Effective and Well-led. The report says it has been rated Requires Improvement or Inadequate for the last three inspections. The provider remained in breach of regulations and was told to submit an action plan.
Medicines
Inspectors found that medicines were generally managed safely and people received them as prescribed.
“Overall medicines were managed safely, and people received these as prescribed.” from the report
Infection control
The home was generally clean and staff followed infection prevention and control practices.
“People were protected from the risk of infection as staff followed safe infection prevention and control practices.” from the report
Health support
Staff worked with health professionals and relatives gave positive feedback about staff communication and knowledge.
“We received positive feedback from a visiting health professional about staff communication and knowledge.” from the report
Staffing levels
seriousStaff were not always deployed in line with people's needs. Some people had to wait for call bells to be answered, and staff could not always provide preferred personal care.
“The provider had failed to ensure sufficient numbers of staff were always deployed to safely meet people's individual needs.” from the report
Environmental safety
seriousItems and substances were not always stored safely. Inspectors also found problems with fire exits, wedged fire doors, an unlocked garden gate and a switched-off door alarm.
“The provider had failed to ensure effective systems were in place to assess, monitor, and mitigate risks to the health, safety and welfare of people using the service.” from the report
Training and supervision
seriousRecords did not show that all staff had completed a robust induction or received supervision. Some staff had not completed safeguarding and infection control refresher learning.
“The provider had failed to ensure staff had received appropriate support, training and supervision.” from the report
Premises
seriousThe dementia unit was not fully dementia-friendly, a shower room had still not been refurbished, and parts of the building needed redecoration.
“The provider had failed to ensure the premises were suitable and properly maintained.” from the report
Management oversight
seriousGovernance systems were not effective enough to ensure risks and previous concerns were resolved. Some care records were incomplete or out of date.
“The provider had failed to ensure systems and processes were operated effectively to assess, monitor and improve the quality of the service.” from the report
- 01What changes have you made to staffing levels since the inspection, and how do you check that call bells are answered promptly?
- 02Have all the fire safety, security and environmental issues found by inspectors now been fixed?
- 03Has the dementia unit been improved with suitable flooring, decoration and signage?
- 04How do you now make sure every member of staff completes induction, safeguarding training, infection control training and supervision?
- 05How do you check that care records, fluid records and oral care records are complete and kept up to date?
This was a focused inspection of Safe, Effective and Well-led after concerns about staffing; Caring and Responsive were not inspected and their ratings were carried over from the previous inspection. This explanation was written from the published report of 29 December 2023 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 2022
St Stephens Care Home is rated Requires Improvement; it has left special measures, but inspectors found ongoing breaches affecting safety, staffing, care and management.
This was an unannounced follow-up inspection over three days. Inspectors spoke with people living at the home, relatives and staff. They observed care and checked care records, medicines, recruitment files and management records.
The home had improved since its previous inadequate rating. Staff recruitment, training oversight, premises safety, nutritional support, safeguarding systems and checks on people's weights had improved. People generally said staff were kind and that they felt safe.
Important problems remained. Risk assessments, medicines records, infection control, staffing levels, care records and management checks were not always reliable. People did not always receive personalised care or enough activities, and some areas of the building needed refurbishment.
All five areas were rated Requires Improvement. This means the service was not always safe, effective, caring, responsive or well-led. The home was no longer rated Inadequate or placed in special measures, but CQC said further improvements were needed and would continue to monitor progress.
People felt safe
People told inspectors they felt safe living at the home. Safeguarding systems had improved and staff training was underway.
“People's feedback indicated they felt safe living at the service.” from the report
Kind staff interactions
People were generally positive about the staff. Inspectors observed kind and attentive interactions.
“During the inspection we observed some positive and kind interactions between people and staff.” from the report
Improved food and nutrition support
Support with eating and drinking had improved. People were generally satisfied with the food, and a better weight-monitoring system was in place.
“A more effective system to monitor people's weight had been introduced.” from the report
Safer recruitment
The home had improved checks for agency staff and recruited staff safely.
“Systems were now in place to confirm agency staff members' identity, training and Disclosure and Barring Service (DBS) status.” from the report
Improved liberty safeguards records
The home had improved its monitoring of DoLS applications and renewals, with applications made where required.
“Appropriate applications had now been made for DoLS authorisations where required.” from the report
Risks were not always managed
seriousSome risk assessments were inconsistent or not robust. Inspectors also found problems with pressure-relieving mattresses, equipment storage, creams, thickening powder, pain assessments and masks.
“These issues were a continued breach of regulation12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Staffing shortages remained
seriousVacancies remained and the home still relied on agency staff. This particularly affected cleaning and activities, and staff feedback about staffing levels was mixed.
“Systems and processes had not been established and embedded to ensure staff were suitably deployed.” from the report
Care was not always personalised
seriousSome people's preferences were not followed, and routines could limit choice. Activities were limited, especially for people who stayed in their bedrooms.
“These issues were a continued breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Person-centred Care).” from the report
Management checks missed problems
seriousAudits did not identify all the issues inspectors found. Care records and safety checks were not always complete, and night staff were not sufficiently overseen.
“These issues were a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Good governance.” from the report
Building improvements were slow
needs fixingSome refurbishment had started, but other areas still needed redecoration. The environment was not dementia friendly and there was no detailed schedule for all improvements.
“However, other areas of the building remained in need of redecoration and refurbishment.” from the report
- 01How many permanent staff vacancies remain, and how are you making sure agency staff have current information about people's risks and care needs?
- 02What has been done to improve night-time management visits and oversight?
- 03How are you making sure each person's care plan reflects their preferences, including personal care, drinks and bedtime routines?
- 04What activities are available for people who remain in their bedrooms, and who is responsible for providing them?
- 05Which risks, incomplete records and audit problems identified in this report have now been corrected?
This was an unannounced follow-up inspection that reviewed all five key questions and checked progress after the previous inadequate inspection and special measures. This explanation was written from the published report of 7 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.
Every inspection of St Stephens Care Home
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2022Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- May 2022InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2022Inspected but not ratedSafe: Inspected but not rated
- March 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2021
Registered with the Care Quality Commission on 12 October 2021.
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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