CQC report explained · a nursing home
What the CQC found at STEPS Neurological and Trauma Rehabilitation Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people felt safe. Medicines, risk assessments, safeguarding, staffing, fire safety and infection control were managed safely.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Well-led?
- Good
- Inspectors found clear management arrangements, up-to-date policies, effective quality checks and a positive culture. People, relatives, staff and professionals were asked for their views.
What inspectors found, June 2021
Rated Good; inspectors found people were safe and well supported, and previous safety problems had been addressed.
This was an announced, focused inspection on 24 May 2021. One inspector and a specialist nurse advisor spoke with four people and eight staff. They looked at the building, care records, staff files and management records.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found safe medicine systems, enough staff, suitable safeguarding arrangements and effective infection control measures.
The inspection followed two previous breaches of Regulation 12 about medicines and risk assessments. The home had improved and was no longer in breach. Inspectors also found stronger management systems and up-to-date policies.
This inspection only examined Safe and Well-led. The ratings for Effective, Caring and Responsive came from the previous comprehensive inspection and were not reassessed in this report.
Medicines were managed safely
Medicines were stored securely, given as prescribed and checked through audits. Inspectors found the medication records they reviewed had been completed properly.
“We checked four people's medication administration records and found they had been completed appropriately.” from the report
Enough staff
Inspectors found enough staff were available to meet people's changing and complex needs. Staffing levels were kept under review.
“There were enough staff deployed to help keep people safe.” from the report
Risks were understood
Care records included risk assessments and instructions for staff. Staff were able to explain how they would help people manage their risks.
“People's care records contained risk assessments. They included guidance for staff on how to reduce each risk.” from the report
Strong management checks
The home had clear management arrangements, current policies and systems for checking and improving quality.
“The provider had effective quality assurance and governance systems in place to assess the safety and quality of the service.” from the report
Positive staff culture
Staff said they felt valued and supported. Inspectors found an open culture and good teamwork.
“There was an open and positive culture.” from the report
Inspectors raised no specific concerns in this report.
- 01What has changed since the previous inspection's breaches about medicines and risk assessments?
- 02How will you assess and review my relative's risks as their rehabilitation needs change?
- 03How many staff will normally be available for my relative, and how do you increase staffing when needs become more complex?
- 04How will you support my relative to manage their own medicines, if this is appropriate?
- 05What were the previous ratings for Effective, Caring and Responsive, and when will these areas next be reviewed?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 12 June 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.
What inspectors found, November 2020
Inspected but not rated; inspectors found unsafe medicines and risk-management shortfalls, although staff training and infection control were in place.
This was an unannounced, targeted inspection on 29 September 2020. Inspectors looked at medicines, staff skills and management. They also checked infection prevention and control because of coronavirus.
The home was not given new ratings. Safe, Effective and Well-led were inspected but not rated. Caring and Responsive were not inspected. The previous overall rating was Good, published in March 2020.
Inspectors found that some risks had not been assessed or followed up. Medicines were not always given safely or as prescribed. The home had breached Regulation 12 on safe care and treatment. Several fixes were made or promised after the inspection.
Staff received regular training and support. Infection control arrangements were judged reassuring. People, relatives and staff said managers were approachable and involved them in the home.
Infection control
Inspectors were assured that the home had arrangements for preventing and managing infections, including the use of protective equipment and testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staff support
Staff had regular training, supervision and support meetings. A thorough induction programme was also in place.
“Staff confirmed they received regular supervisions and appraisals, as well as regular staff support meetings and drop-in sessions.” from the report
Involvement and culture
People, relatives and staff were involved in how the home was run. Feedback described managers as approachable and willing to listen.
“People, relatives and staff were engaged with and involved in how the service was run.” from the report
Learning from incidents
Accidents and incidents were recorded and reviewed. Staff discussed incidents to help reduce future risks, although the monitoring process was still becoming established.
“Incidents were reviewed by the Head of Nursing, who tracked actions from these to mitigate against future risks.” from the report
Risk assessments
seriousSome people did not have the risk assessments or monitoring needed for their health conditions. The report says this put people at risk and breached Regulation 12.
“Risks to people's safety were not always assessed and action to mitigate these risks was not taken.” from the report
Medicines
seriousPeople did not always receive medicines as prescribed. Systems for controlled drugs, topical medicines, as-needed medicines and self-administration were not always safe or complete.
“People were not always receiving medicines as prescribed.” from the report
Safeguarding records
needs fixingThe system for recording and tracking safeguarding concerns was not effective. The provider was asked to improve this process.
“The system used for recording safeguarding concerns was not effective.” from the report
Management oversight
needs fixingThe audit system had not identified the problems found by inspectors. The risk register was not up to date, and managers were not always clear about their regulatory duties.
“An audit tracking system was used to ensure all aspects of the home were checked and analysed, however, this was not working as effectively as it could be because the concerns we found had not been identified.” from the report
Registered manager
minorThere was no registered manager in post when inspectors visited. The home had interim plans for the role.
“A registered manager was not in post when we inspected.” from the report
- 01What has changed in the medicines system since this inspection, including records for controlled drugs, topical medicines and as-needed medicines?
- 02How are risks such as seizures, medical emergencies and self-administered medicines assessed and reviewed now?
- 03How are safeguarding concerns recorded, tracked and reported to CQC?
- 04Who is the registered manager now, and how is the home being overseen?
- 05How do audits check that the problems found in this report have not happened again?
This was a targeted inspection of Safe, Effective and Well-led, focused on medicines, staff skills, management and infection control; Caring and Responsive were not inspected and previous ratings were carried forward. This explanation was written from the published report of 11 November 2020 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 STEPS Neurological and Trauma Rehabilitation Centre
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- June 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at STEPS Neurological and Trauma Rehabilitation Centre →
- November 2020Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedWell-led: Inspected but not rated
Read what inspectors found at STEPS Neurological and Trauma Rehabilitation Centre →
- March 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2018Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017
Registered with the Care Quality Commission on 26 April 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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