CQC report explained · a nursing home
What the CQC found at St Stephens Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Inspectors found safe recruitment, enough staff, suitable risk assessments and safe medicines management. The Safe rating improved from Requires Improvement at the previous inspection.
- Effective?
- Good
- People's needs were assessed and reviewed with them and their relatives. Staff received induction, training and supervision, and people were supported with nutrition and healthcare.
- Caring?
- Good
- Inspectors saw positive, kind and respectful interactions. People were involved in decisions, and staff supported their privacy, dignity, independence and relationships.
- Responsive?
- Good
- Support plans reflected people's current needs and preferences. People could choose activities, use community facilities and complain in an accessible way.
- Well-led?
- Good
- Inspectors found clear leadership, regular audits and an open culture. People, relatives and staff were involved through meetings and feedback.
What inspectors found, July 2019
Rated Good; inspectors found safe, kind and person-centred care, with no breaches reported.
This was an unannounced inspection on 25 June 2019. The inspectors spoke with all 16 people living in the home, staff and visiting support workers. They reviewed care and medicines records, staff files, policies and quality checks.
The inspectors found that people were safe and protected from avoidable harm. Staff were safely recruited and trained. Medicines were managed safely, care plans were up to date, and people were supported with health appointments, food, activities and community life.
People described the home positively. Inspectors saw kind and respectful interactions, and found that people had choice and control over their daily lives. All five areas were rated Good. The overall rating was unchanged from the previous inspection, while the Safe rating improved from Requires Improvement to Good.
People feel safe and happy
Everyone inspectors spoke with felt safe and positive about living in the home.
“Everyone we spoke with felt safe living in the service, they were all very happy.” from the report
Choice and independence
People were supported to make everyday choices, develop skills, take part in activities and use local community facilities.
“People were supported to have maximum choice and control of their lives.” from the report
Kind and respectful care
Staff knew people well and treated them with kindness, dignity and respect.
“The interactions between people and staff were positive, caring and inclusive.” from the report
Safe medicines
Registered nurses managed medicines safely, with no gaps or omissions found in the medicines records reviewed.
“There were no gaps or omissions which indicated people received their medicines as prescribed.” from the report
Good oversight
The manager used audits, meetings and feedback to monitor the service and act on any shortfalls.
“There were effective systems in place to monitor the quality of the service.” from the report
Larger than current best-practice guidance
minorThe home was registered for up to 17 people and had 16 residents. Inspectors noted that its size was larger than current best-practice guidance, although they said the building design reduced the negative impact.
“This is larger than current best practice guidance.” from the report
- 01How will you assess and manage my relative's individual health and nursing risks, including any pressure-area risks?
- 02How will my relative be involved in writing and reviewing their support plan?
- 03What activities and community opportunities would be available for my relative, based on their interests and independence goals?
- 04How would you support my relative's communication needs, including the use of easy-read or pictorial information?
- 05How do you make sure medicines remain safe and are reviewed when needed?
This was an unannounced inspection covering the premises and care provided, with all five CQC questions rated. This explanation was written from the published report of 16 July 2019 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, November 2016
St Stephens Nursing Home was rated Good overall, but inspectors found that safety procedures and medicines management still required improvement.
This was an unannounced comprehensive inspection on 5 October 2016. Inspectors spoke with all the people living at the home, staff and relatives. They reviewed care records, medicines, staffing, training, recruitment and quality checks, and observed care and activities.
The home had improved since the previous inspection, when it was rated Requires Improvement and breaches were found. Staff training, recruitment checks and staffing levels had improved. Inspectors found kind, respectful and personalised care, good support with health needs, activities and daily choices, and open leadership.
The safe rating was Requires Improvement. Safeguarding procedures had not been followed on three occasions, a special mattress had been switched off, and there were some medicines recording and handling problems. The manager took immediate action during the inspection. The other four ratings were Good, so the overall rating was Good.
Caring staff
Staff treated people with kindness and respect. They understood non-verbal communication and responded to people's wishes.
“Staff were caring, kind and respected people's privacy and dignity.” from the report
Personalised support
Staff knew people's histories, preferences and care needs. This helped people build confidence, make choices and become more independent.
“This continuity of support had resulted in the building of people's confidence to enable them to make more choices and decisions themselves and become more independent.” from the report
Activities and choice
People could choose from activities inside and outside the home, including social events, music groups, exercise classes, shopping and trips out.
“People were supported to participate in a variety of activities that they enjoyed and that were tailored to their needs and choices.” from the report
Staffing and recruitment
Inspectors found enough staff on duty, with a stable team. Recruitment checks had been completed before staff started work.
“There were enough staff, who knew people well, to meet their needs at all times.” from the report
Safeguarding reporting
seriousOn three occasions, incidents that should have been referred to the local safeguarding team were not referred. The manager acted during the inspection to seek advice about future incidents.
“Safeguarding policies and procedures had not been consistently followed.” from the report
Pressure-relieving mattress
seriousA special mattress had been left switched off and was not set with clear guidance for the person's needs. The manager introduced twice-daily checks during the inspection.
“A person was potentially left at risk as the power supply to a special mattress to protect their skin and reduce the risk of pressure sores developing had been turned off.” from the report
Medicines controls
seriousOne medicine was not dated when removed from the fridge, creating a risk it could be kept too long. A nurse also carried two medicine trays at once, although the risk of confusion was described as minimal.
“People's medicines were not always managed as safely as they could be.” from the report
Accessible care plans
minorCare plans contained detailed information but were not written in a way that made them easy for people to understand.
“The care plans were not written in a way that would make them accessible and easier for people to understand.” from the report
Sharing feedback results
minorThe home asked relatives and other stakeholders for views, but did not share a summary of the results or the improvement actions.
“There was no summary or publication to people, staff and stakeholders of the results, to show continuous improvement and the action the registered manager was taking.” from the report
- 01What checks are now used to make sure safeguarding concerns are referred to the local authority when required?
- 02How often are pressure-relieving mattresses checked, and how is the correct setting for each person recorded?
- 03How do you make sure medicines removed from the fridge are dated and discarded at the right time?
- 04What has been done to make care plans easier for people to understand?
- 05How are feedback results and improvement actions now shared with people, relatives and staff?
This was an unannounced comprehensive inspection covering all five key questions and checking improvements made since the previous inspection in August 2015. This explanation was written from the published report of 9 November 2016 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 Nursing Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- July 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 January 2011.
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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