St Stephens 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 abuse and avoidable harm.

At our last inspection, we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

At our last inspection, we found the provider was in breach of regulation 12 (safe care and treatment), due to risks identified within the environment and regulation 18 (staffing), due to staff not responding to people in a timely way. At this assessment we found the provider had taken enough action and was no longer in breach of regulation.

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Any incidents were discussed during handovers and staff meetings to learn from safety incidents and to help prevent recurrence.

The provider had demonstrated a learning culture by learning from and acting on the findings at the last assessment. The manager told us, “That was our starting point – to put it right and learn from it, we are always looking to improve.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

One relative shared with us their experience of their loved one moving into the service from an alternative care provider, they told us how the person had settled in well and how it had been a smooth transition.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns with external agencies such as the Local Authority, quickly and appropriately.

Staff told us they wouldn’t hesitate to act on any concerns, one member of staff told us, “I know what to do if there was an incident. I wouldn’t ignore it; I am aware of different types of abuse.”

People told us they felt safe living at St Stephens Care Home, one person told us, “Yes, I feel safe and happy. I am well looked after.”

The provider worked with people to understand and manage risks in a way which reflected their choices and preferences. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Any accidents and incidents were analysed regularly to help identify any trends and themes and to help preventative measures to be implemented in a timely way.

Since our last inspection, a full-time maintenance person had been recruited to help ensure all health and safety checks were completed. Fire exits were kept clear and any substances hazardous to people, such as cleaning substances, were safely locked away.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Since our last inspection, bathrooms had been refurbished which included the installation of a modern and spacious new wet room.

Signage had been placed in the unit for people living with dementia to help them better navigate around the environment. Although some improvements were still needed to meet the needs of people living with a cognitive impairment, the provider was keen to tell us about the plans in place to introduce changes and adaptations to the environment and how they were in consultation with external specialists in dementia to help implement this.

At the time of our assessment, the provider was also in the process of introducing new technology designed to improve care and support to people at risk of falls.

We observed some potential hazards in the garden area as some of the paths were overgrown. However, the manager explained how plans were in place to recruit a regular gardener to help overhaul the space and make it more accessible to people.

We also observed an unlocked room used to store equipment such as hoists, as this was accessible to people it posed a risk. The manager arranged to have a lock fitted during our assessment.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We did note moving and handling competencies for some staff were out of date, however the manager confirmed this was being actioned.

The manager explained support and training processes for staff had been strengthened since our last inspection, they said, “The induction process is much improved, staff complete all training before they start and are allocated a buddy to help them get to know the service.”

Staff told us they felt they were provided with the training and support they required. One staff member told us, “I feel supported and well trained.” One person’s relative confirmed, “Staff are very person centred, the care is really good, and staff seem well trained.”

We received some mixed feedback about staffing levels from people and staff, one person told us, “I would say its busy and they could do with more staff.” A member of staff told us, “It can be busy in the mornings and at mealtimes and it would be nice to have more staff then, but we still get it all done and I feel people are safe.” A relative told us, “I visit a few times a week, and I would say there are enough staff.”

We observed staff responding to people’s call bells in a timely way. For some people who were not able to use call bells, an alarm was set off every time they left and entered their room. We spoke with the management team about the consideration of less invasive ways to responding to people’s needs.

Policies were in place to help assess and manage the risk of infection. The service was largely clean and well maintained. However, we observed the kitchenettes on both units were dirty, for example, on 1 unit, a spillage had been left in the microwave. The main kitchen was also unclean with grease and food stains evident on the walls and some crockery. Debris had also collected behind the fridges and freezers. We observed some fridges within the home were icing up. The veneer on the fridge in the main kitchen had partially come away impeding the ability to clean it. We noted gaps in the recording of kitchen cleaning schedule records.

Cooking vats contained dirty cooking oil which required changing. We fed our concerns back to the management team who acted on our findings right away and began a deep clean of the kitchens. Additional audits were also implemented to help ensure the kitchen remained clean.

People’s equipment also appeared unclean, such as crash mats, located next to people’s beds. We also observed the first aid box had some out-of-date items, such as dressings and saline. We informed the manager about this.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were managed safely. We observed that some protocols for PRN (as and when required medicines) required more person-centred detail to help better guide staff on when to administer them.

Monthly medicine audits and clinical risk meetings took place to ensure medicines and treatments were safe and met people’s needs. The manager told us they had a good relationship with both their prescribing GP and pharmacy.