St Stephen's Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from avoidable harm. At our last inspection this key question was rated requires improvement. At this assessment this key question remains at requires improvement. We identified continued shortfalls with medicines, clinical care, infection prevention and control and the environment. We found significant shortfalls in the environment which was not always safe, and risks were identified around infection prevention and control (IPC), medicines, clinical documentation and oral care. The providers internal audits did not always identify the risks we found during our inspection, however, the provider was responsive and started to take immediate action during our visit. Systems were not robust to monitor and mitigate risks to the health, safety and welfare of people using the service and lessons had not always been learnt. This placed people at increased risk of harm. This was a continued breach of regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People's feedback raised no concerns regarding the learning culture within the organisation.

Staff were aware they needed to report any accidents and incidents and told us appropriate action would be taken. They shared how they had used learning tools with their colleagues when they started, to gain better understanding of people’s needs and where they were located in the building. For example, 1 staff member told us, “When I started, I did shadowing and completed the required training, however, I wanted to gain further understanding about people’s specific fortified diets so I spent time watching videos of how to ensure dietary requirements were prepared correctly”.

The provider had a shared learning tool policy for staff to reference after any accidents or incidents. This outlined the process staff should follow. Some of the incident information lacked detail with what had happened during the accident or incident and required further development. During our assessment, the provider accepted our feedback, and some improvements were made. Actions had been taken to reduce the risk of infection and guidance had improved in relation to people’s oral care. However, further improvements were still required to ensure people’s individual needs were met.

People and relatives were supported by the provider when they transferred services. Some relatives told us they had met with the registered manager during an assessment to share information about people’s support needs before they were admitted to the service. The service supported people on respite care, we saw care plans had been devised and developed since their admission to the service.

Staff told us they had the relevant information they needed to meet people’s needs when they arrived at St Stephens Care Home. Staff told us of how they worked with external professionals to ensure people received the correct referrals, care and equipment required to support their needs as they transferred between services.

We sought feedback from professionals; however, we received limited information from them in relation to this key question. Two professionals confirmed they worked with the service to provide care and support. One professional said the service supported safe transitions.

The provider had processes in place to support transitions between services, we saw evidence of pre assessment processes in people’s care plans.

People and relatives told us they felt safe living at St Stephens Care Home. One person told us, “I feel safe you have got other people with you”. Another person told us “I feel safe, I can hear people walking about at night”.

Staff understood how to protect people from harm and knew how to report concerns. A member of staff told us, “I feel confident raising safeguarding concerns if needed. If I see something that needs a safeguarding referral, I go to the manager. If nothing happens, I inform the safeguarding team, CQC and the police.” Another member of staff told us, “We need to report incidents to our seniors and managers. If they do not listen, we need to report it further to CQC".

We observed most staff supported people safely. However, some staff members failed to recognise when people may be at risk from the Control of Substances Hazardous to Health (COSHH) not being locked away securely on both occasions of our onsite visits.

The provider had safeguarding policies and processes in place to protect people from the risk of abuse. Where people lacked capacity applications had been made to the local authority and best interest’s decisions has been carried out in consultation with people and families where appropriate. The provider had a robust record in place to keep a track of referrals that had been made.

People and relatives did not raise any concerns in relation to being involved in managing risks relating to their care and support. Where people had specific life choices which may pose a risk to them, risk assessments had been carried out. However, 1 person told us they needed to call for staff help, as another person had had a fall and staff took time to respond to the call bell when they needed assistance. We shared this with the provider who told us they would review their call bell audits for timescales when they are responding to people.

Staff gave us examples of how risks were posed to people and how they were supported. For example, 1 staff member told us how they supported a person to work alongside staff in the laundry as this used to be part of their previous employment. Staff told us they knew people’s needs well and had the necessary skills and training to support them safely.

We observed people who were able to walk around freely in the communal areas. We observed staff carrying out safe transitions when supporting people with moving and handling practices.

Risks relating to the service and to individual people were assessed. These included risks associated with the environment, mobility, skin care and eating and drinking. Risk assessments formed part of the support plan for each person. They provided guidance for staff about how to keep people safe, however, these did not always detail people’s specific needs. For example, care plans and protocols did not always detail what actions to take when managing people’s anxious behaviours. This posed a risk to people as staff may not be offering a consistent approach.

People and relatives did not raise any concerns with the environment. One person told us, “I have my own rise and recliner chair which I use, and staff support me”.

Managers told us they were currently renovating parts of the downstairs of the home, which we observed on our visits. The maintenance person shared their responsibilities with maintaining a safe environment for people, and what actions they would take if there were any faulty or damaged equipment. However, we identified actions had not always been taken. For example, 1 person’s toilet was broken, this had been identified in the last 2 monthly resident meetings but had not been fixed.

During our observations we found multiple risks. We observed the Control of Substances Hazardous to Health (COSHH) products had not been safely locked away on both onsite visits, despite being shared with the provider on the first visit. We also identified the kitchenette area on the first floor did not have food labelled in the cupboards or the fridge in line with Environmental Health guidelines. Prescription creams were also not stored safely. Despite sharing this with the provider on the first day of our assessment, prescription creams continued to not be been stored securely on our second visit.

People had personal emergency evacuation plans (PEEPs). A PEEP sets out the specific physical and communication requirements which each person has to ensure people can be safely moved away from danger in the event of an emergency. However, the list of people in the emergency fire grab bag was confusing and contradictory. The first page stated there were 45 people, but the next page stated there were 46 people to be evacuated. We raised this issue with the provider who addressed this and corrected the PEEP list. There were appropriate environmental checks in place, however, the service did not always take appropriate action to reduce potential risks relating to Legionella disease. There were gaps in some environmental weekly checks. There were also no monthly health and safety bedroom checks in June 2024. These shortfalls had not been identified by the provider until our visits.

We received mixed views from people on the service’s staffing levels, some people told us, “Staff are there if we want them” and “Always staff about no problem”. Other people said “Short staffed, can see it, don’t want to get involved as its not affecting me, two bells in dining room I use them if someone falls, it happened a couple of days ago and waited half an hour as there was a cross over of staff” and “Sometimes can’t find staff, usually late afternoon, another person was not very well and it took ten minutes, it is a long time when someone ill”.

Staff told us there were enough staff to meet people’s needs and keep them safe. Staff shared positive feedback on their training and felt it had provided them with the necessary skills to carry out their roles. They told us they had opportunities to develop their skills and knowledge should they wish to.

We saw there were enough staff to meet people’s needs and to keep premises clean, however, staff were not always deployed effectively. For example, on the first day of our visit we saw staff were busy on the first floor. They provided support to people who were unable to leave their rooms and eat meals independently. They also supported people who needed assistance with their continence needs. Staff did not always recognise when some people required assistance, inspectors needed to alert staff on several occasions when people required help and support. This improved on the second day of the inspection when the deputy manager offered to support to staff on the first floor.

People were supported by staff who had appropriate experience and were of a suitable character to work with people. The service had recruitment processes in place. Pre-employment checks were completed for staff. These included employment history, references, and Disclosure and Barring Service checks (DBS). A DBS is a criminal record check.

People and relatives did not raise any concerns in relation to the cleanliness of the environment.

Domestic staff told us they were responsible for cleaning a floor each, which consisted of communal areas, people’s bedrooms and bathrooms. We asked which areas had already been cleaned, some of which were still extremely dirty with a risk to people of cross infection. Staff told us they had reported broken clinical waste bins to managers; however, no action had been taken to replace them. This was also evidenced in the staff members supervision record. Most clinical and disposal waste bins were not in working order, this place people at risk of infection.

On the first day of our assessment we found some areas of the premises were dirty. In some bedrooms, we found dried faeces stains on bedding, doors, and in one room on a sealed catheter bag. The environment in which people were provided with care was neither safe nor clean. We saw the majority of clinical waste bins were broken. We reported this to the provider who addressed some of our concerns. On the second day of our assessment we saw the premises was cleaner.

The service had a policy and procedure in place for Infection Prevention and Control (IPC). There were walkaround and housekeeping audits completed by the registered manager, and a night visit audit had been completed by the area manager in August 2024. However, these audits were ineffective as they had scored 100% for IPC and had not identified the concerns we found during our assessment.

People told us they were happy with how they were supported with their medicines. One person said they would prefer to do their own medicines with the support of staff. We shared this with managers who assessed and explored this option with the person.

Staff told us they had received the relevant training and competencies to administer medicines safely, and this was evidenced through training records. However, staff did not always follow best practice when administering, dispensing and recording medicines. For example, some handwritten medication administration records (MAR) charts developed by staff were illegible and lacked detail. We saw some ‘when required’ (PRN) medicines were not given within the correct allocated timescales, and time specific medicines were not specified to ensure the person took them as advised by the prescriber. We shared this with the management team who took immediate action to address the concerns.

The provider had a medicines policy in place which required updating. Some of the information in the policy was out of date and inaccurate. We shared this with the provider who advised us it would be reviewed by a competent staff member to ensure the information was updated and in line with current legislation. On both days of our assessment, we found topical creams were not always stored safely. PRN protocols for people who required medicines to manage anxious behaviour, lacked detail of how the person may present, and what staff could do to support them safely and effectively. Medicines which required returning to the pharmacy were not always logged to ensure the provider had a clear audit of what medicines had been returned. Some diabetes protocols required additional information and not all people who were taking anticoagulant medicines had risk assessments in place. We shared this feedback with the management team who started to take immediate action after our first onsite visit.