St Stephen's Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection this key question was rated requires improvement. At this assessment this key question remains at requires improvement. We identified improvements were needed in management oversight and governance in relation to medicines, staffing, Infection Prevention and Control (IPC), clinical care documentation and oral care . Managers were responsive to our feedback and told us they were committed to improve the safety and quality of care being delivered and had put an action plan in place. However, these were not yet embedded and some documentation which had been provided to inspectors required further details. The systems for governance and oversight had not always been effective in identifying the service’s shortfalls. People and families spoke positively about managers. The provider’s oversight and governance failed to ensure systems and processes identified the improvements needed in the quality and safety of care being provided. This was a breach of Regulation 17, (Good Governance), of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager told us they valued their staff and recognised good performance. They told us how staff developed in their roles and were keen to learn more, and described staff as kind and caring. The service was no longer using agency staff which both staff and managers felt were improving consistency with delivering care to people. There was an incentive ‘employee of the month’ scheme where staff were awarded for going above and beyond their duties. This was well received by staff. Managers told us they understood the importance of gathering and listening to people and their relative’s views on the service, but this needed further improvement to ensure this was captured and demonstrated in people’s care planning and reviews.

The provider shared their statement of purpose which aimed to promote a positive and supportive care culture. Compliments received showed this was evident and appreciated by people and their relatives. The provider shared their action plan which included steps they were taking to improve their safety and governance systems in order to monitor the environment, medicines and care records more efficiently.

The registered manager had been registered with the CQC since March 2024. We received positive feedback from staff who told us they could approach them with any concerns, and they felt appropriate action would be taken in response to raising them. An annual survey conducted by the service showed 85% of the team agreed they have good communication with their line manager and felt they could share concerns and ideas with them.

Some people we spoke with told us they were unaware of who the manager was. Managers acknowledged they had not always identified shortfalls we found during our assessment in relation to the environment, staffing, medicines and auditing. Records showed where required, the provider had notified CQC of events they were required by law to do so and the management team demonstrated a good understanding of when to report to the CQC and the local authority. Incident records showed that relatives and healthcare professionals had been informed where incidents had occurred. After sharing our findings, managers were reflective of our feedback and kept inspectors updated regarding the progress which had been made during and after the onsite assessment.

Staff had opportunities to make suggestions and contribute to the development of the service at staff meetings, surveys and through the provider's supervision procedure. A member of staff told us, “The management are supportive. We can share our ideas during staff meetings.” One staff member told us how they had identified there were a high number of falls at the service. They had made suggestions to the management team to invest in additional falls monitoring equipment and new profiles beds, which had supported a reduced number of falls at the service.

The provider had a whistleblowing policy in place. This detailed how staff could raise concerns internally to the provider, and listed the external bodies they could escalate concerns to. Some people we spoke with were unsure of where, and who they could raise concerns to. Systems to encourage people using the service to be able to communicate and speak up would benefit from further improvement. Particularly for people where English is not their first language. The provider held regular people, staff and relative’s meetings and actions were noted and assigned to the relevant person.

Staff told us they were treated equally and were happy to work as a team. A member of staff told us, “Our staff team is diverse, very diverse. I think the team is working quite good.” Staff told us there was good teamwork, they felt involved and were encouraged to attend team meetings.

The provider had policies in place to support fair recruitment, induction and training for all staff. The registered manager had appointed some staff members to carry out champion roles. Some of these included IPC, oral care, medicines and dementia. However, we found shortfalls in these areas which had not been identified by the management team.

Staff told us they understood their roles and responsibilities. The registered manager told us they received support from the regional support manager and attend monthly meetings with the provider. They said they felt assured they could ask for support if needed. We observed the registered manager engaging with people and staff in a relaxed and knowledgeable way.

There were systems in place to monitor the quality of the service. However, these had not always been effective at identifying where improvements were needed. For example, issues relating to medicines documentation, poor infection prevention control and poor oral care remained unaddressed until our visit. Some issues had been highlighted in a quality audit in July 2024 around time specific medicines and catheter care, however these had not been actioned until our visit.

People and relatives spoke positively about collaborative working with the service and external professionals. Relatives said they were kept informed of any changes to their loved one’s care. Peoples care plans demonstrated where referrals had been made.

The provider told us they work in partnership with other managers and had monthly managers meetings. There was evidence in people's care plans of the service working collaboratively with external professional's and the management team shared updates with people and families. The service held daily handover meetings where updates and clinical care changes were discussed, and actions set for any tasks which required completing.

During our assessment visit we saw the provider had developed relationships with external entertainers and a local school. On the second day of our assessment, we saw children visiting the service. External professionals told us staff implemented changes to peoples care as recommended.

The registered manager and staff worked in partnership with external care professionals to ensure people received joined-up care. People's care plans clearly contained advice from other professionals.

Staff told us they were actively encouraged and involved in discussions around improvement. A member of staff said, “We are asked what things we can change to benefit our residents". There was evidence of the service using innovation to improve people’s quality of care, for example, in the form of communication cards for a person who did not speak English. However, we did not witness staff using them during our onsite visits.

At the last inspection the provider needed to make improvements with the administration of medicines and associated records, we also identified some inconsistencies with guidance in people’s underlying health conditions. Some of these improvements had not been made and we found continued shortfalls at this assessment. The management team had a lesson’s learnt process which demonstrated where incidents had occurred, how they could be prevented and what actions had been taken. However, they had not highlighted some of the continued concerns we found during our assessment, and therefore action had not been taken. Managers had started addressing some of the issues raised on the first day of our assessment and had devised an action plan. On the second day we saw some improvements with oral care guidance, medicines documentation and overall cleanliness of the service. However, after this was shared and reviewed by us, it still required further development and embedding to ensure any future shortfalls were identified and actioned during the service’s auditing processes.