Stable Steps Care Centre

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 abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to the provision of safe care and treatment, risk management and the management of medicines.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

There was limited evidence that lessons were learnt. We found some examples where people had experienced multiple incidents of harm or risk of harm, but there was limited evidence all the actions required to mitigate these had been undertaken. For example, there were a number of people who required close monitoring and were commissioned for 1:1 support; however, there was limited assurances this level of staffing was used to improve the persons quality of life. Staff were seen sitting with people with limited interaction or following them as they moved around the building. There were limited assurances that despite enhanced staffing levels for some people, this had reduced the risk, especially in relation to distressed behaviour.

Not all concerns found at previous inspections had been fully addressed. For example, in regard to the storage of medicines, the safe administration of medicines which needed to be given covertly and the rotation of medicated patches. We also found a continued lack of oversight in relation to staff training, issues with how people were supported with care, which was personalised to their individual needs and preferences, and issues with managing the risks associated with people going into others’ bedrooms.

The provider did not always work effectively with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

The registered manager told us about their close working relationships with other services including the local older adult’s mental health service. Records demonstrated referrals were made to services where this was needed, but it was not always clear concerns had been escalated as quickly as possible to prevent a crisis, for example, when seeking support for someone’s mental health with psychiatric services. Several people at the home had input from other healthcare agencies, including those people on 1:1 care and support. However, we found advice given by healthcare professionals was not always effectively followed and had not always translated into good care for people. For example, our observations and care records viewed demonstrated one instance where a care plan that had been devised by a healthcare professional was not being followed.

We found some shortfalls in how care was provided to people who had fragile skin and were at risk of developing pressure injuries. This included a lack of guidance for staff on how to manage people’s active wounds and in escalating concerns where people were refusing care and a change of dressing.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

We were not assured safeguarding concerns were reported effectively. Multiple incidents had occurred between people living at the home, where people had come to harm or been placed at the risk of harm, and it was not always clear this has been effectively escalated or investigated fully to keep people safe. For example, we found one person was a risk of putting non-food items in their mouth. Whilst the risk of equipment such as disposable gloves had been noted as a risk, the action to ensure the equipment was not readily accessible had not been completed in a timely way and we witnessed this person putting inedible items in their mouth. We noted records contained repeated incidents of the same nature and involving the same people, where no robust and effective action had been taken to mitigate the risk of future incidents. For example, we found records of 2 people who had been involved in multiple altercations involving both verbal and physical abuse. As a result, we raised a safeguarding alert with the local authority.

People’s views of feeling safe was mixed, with people and families raising concerns about the amount of people who would go into others’ bedrooms. One person commented, “They [staff] could do better in stopping other people going into other people’s rooms. They have gates, but some just push them open.” Another person commented, “Some of the other residents can be aggressive and come in your room but the staff seem to contain the trouble.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had a range of risk assessment and care plans but these were not always subject to regular review and were not always updated when needs changed or an incident occurred. Care documents did not always include detailed and person centred information to guide staff on how to effectively manage people’s needs. For example, where people had been the victim of an incident, it was not always clear what staff needed to do to mitigate this risk. Where people were at risk of becoming distressed or aggressive, care plans did not provide robust and detailed guidance on how to reassure and distract the person effectively in order to reduce the risk of unexpected outbursts.

In instances where some action to mitigate risk was recorded within a care plan, this was not always being followed by staff. For example, one person’s care plan stated they should be supported to eat in a quiet area to reduce the risk of them eating from other people’s plates, but this was not being followed. Another person had been involved in a significant number of incidents involving both verbal and physical abuse of other people and staff. Their care plan for behaviours that challenge was not robust and comprehensive in guiding staff to support them and keep other service users safe. Actions to mitigate risk were not detailed or person-centred, they included general actions such as monitoring, redirection of other service users, documenting incidents and reporting to the nurse.

There was limited evidence that people and families were involved in making decisions in relation to the management of risk. We reviewed a sample of people’s resident of the day records, where reviews of care and documentation were recorded, and did not see any evidence that people or their families had been involved in these reviews and there was no record of any input or feedback.

Feedback during our inspection from some people and relatives was positive about how risk was managed. One relative commented, “[Family member’s] not had any falls lately that’s why they have the mat. If [family member] does have a fall they have to call an ambulance to check on them.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

At the last 2 inspections in 2022 and 2023, we raised concerns about people having access to a safe outside space. After each of these inspections, the provider had told us of their plans to landscape the outside space and make it appropriate and safe for people to use. At this inspection we continued to have concerns about the safety of the outside space and found the stated improvements had not been implemented. The ground floor pathways at the rear of the building remained a trip hazard due to uneven surfaces and there was limited suitable and clean seating for people. The first floor had an outside balcony area; however, this was used entirely by people for smoking, meaning other people living on the unit did not have ready access to a safe and comfortable outside space. This balcony area was unclean, with discarded cigarettes and holes in the chairs used by people who smoked. The entrance to the balcony area was accessed by two pieces of wood and we were not assured this provision was in line with health and safety regulations around dual access ramps.

At our last inspection in 2023 we found records did not always demonstrate action had been taken following health and safety checks, as similar concerns were noted at this inspection. For example, the home’s fire risk assessment contractor had raised concerns about the use of safety gates, which were in place in some people’s bedroom doorways to stop people going into others’ bedrooms. These gates had been identified as posing an additional risk in the event of an emergency. It was unclear what action the provider had taken to mitigate this risk and we found people and their families had not been informed of this potential risk when using the safety gates.

Where people’s skin integrity was at risk and they required an air flow mattress to protect them from skin breakdown, we found these mattresses were not always set correctly in line with people’s individual weight and it was unclear there were suitable systems of checks for this being completed.

We found other health and safety checks had been carried out and were up to date. However, we were unable to view checks for the lift and the maintenance of electric beds during our site visits. The registered manager told us they would send them to us via email; however, these were not produced after the inspection.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

At the last inspection we found concerns in relation to the recruitment of staff and staffing levels. At this inspection we found these concerns had mostly been addressed. We received mixed feedback about staffing levels; we were told of some delays in how staff responded to people’s call bells and we received comments that staff were very busy. However, we observed there were suitable numbers of staff available to support people, including at busy times such as mealtimes.

At this inspection we found some concerns in relation to staff’s knowledge and ability to meet the needs of the complex people they were supporting. For example, the registered manager told us staff had completed specialist training to meet the needs of people living at the home, but it was not evident from our observations, or documented in care plans, that this training had been implemented effectively and translated into the delivery of care and support. We were not assured staff were knowledgeable, experienced, skilled and competent to provide the necessary care and support for people with specific needs relating to dementia and other cognitive impairments, particularly when they became distressed due to their conditions.

At our last inspection we received some concerns from people and relatives about language barriers and effective communication between staff and people living at the service and this continues to be an area of concern. One person commented, “I can’t understand the staff sometimes because their English isn’t very good but we get there in the end.” However, we did see staff responding to people in a kind and sensitive manner.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The home had a team of ancillary staff for cleaning and laundry. We found the home was free from malodours; however, we found some shortfalls in cleanliness. Not all areas of the home were fully clean and we found the ground floor shower room, including the wheelchair commode, to be particularly unclean. We noted plastic beakers used to provide people with drinks, did not always appear clean and were stained. We found people’s toiletries were not always stored safely to protect the risk associated with cross infection. We observed some people had dirty fingernails and toenails and, although there was evidence in records that people were being supported to have showers and access to the visiting podiatrist, it was not clear these areas of personal care were being closely attended to.

The registered manager told us they provided training for staff in infection prevention and control and carried out regular audits to ensure the cleanliness of the home. We observed staff wearing the necessary PPE when providing care and support. However, we also found limited evidence people were having regular and appropriate oral care. Many toothbrushes we checked had not been recently used, records of oral care were not being consistently maintained and some people we spoke with had unclean teeth. Some people suggested to us showers were provided on a rota basis, by mentioning the day of the week they were able to have a shower. One person told us, “I have a shower about 2 times a week.” The registered manager told us this did not happen and people could have a shower whenever they liked. However, we found there were only 2 showers in the building for up to 50 people.

The provider did not always ensure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were managed inconsistently. Some aspects of medicines’ management were safe, for example, medicines were mostly accounted for, staff administering medicines had received training and were assessed as competent. However, some medicines were not managed safely. We found concerns raised at the last inspection had not always been addressed and improved.

People were not always supported to take their medicines safely. At our last inspection we recommended the provider consider good practice guidance when developing systems for the safe management of medicines. We found systems for these checks had not been effectively actioned.

Where a prescription had specific manufacturer’s guidance about how medicines should be given, it was not clear this guidance was being followed by staff when administering the medication, for example, where medicines should be given before food and other medicines.

The provider was not effectively making use of body maps to safely monitor the location of insulin injection sites or where medicine patches were placed on a person’s body. Therefore, we could not be certain risks were being safely mitigated in line with manufacturer’s guidance. This issue was raised at the last inspection of the service.

Information about how and when to administer, medicines prescribed to be given as required (PRN), for example to manage pain, was not sufficiently detailed. We noted processes to follow up the effectiveness of medicines given on an as required basis were not being consistently used. These medicines given as and when included those used to treat pain, anxiety and agitation. Where people required their medicines covertly, for example, hidden in food or drink, it was not clear that guidance on how to do this safely and effectively had been sought, as people who were receiving their medicines covertly did not always have a pharmacist assessment of how these medicines should be prepared and administered.

Checks to ensure medicines were being securely stored and in line with the manufacturer’s guidance were not taking place consistently, the necessary recording of opening dates for liquids and creams were not being consistently completed to ensure these medicines remained effective and in date for use.