St Stephens 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 assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At our last inspection, we found the provider was in breach of regulation 17 (governance) due to a lack of oversight to safely manage and mitigate risk. At this assessment we found the provider had taken enough action and was no longer in breach of regulation.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The manager told us, “I am passionate about people receiving good care. We work as a team, and I consider us a family here. We don’t just look after the people we look after their families too.”

This ethos was shared and understood by staff. One member of staff told us, “I understand my purpose here, to support people to live the way they wish to, to carry out my duty of care to ensure this happens, to treat everyone with dignity and to respect and respect their instructions and desires.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Since our last inspection, there had been significant changes in the structure of the senior management team. Whilst further time was needed to embed improved practices, leaders told us how they were keen to improve the standard of delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively and did so with integrity, openness and honesty.

The manager told us, “We have a good stable staff team here and we all feel passionate, it’s not just a job, we all own it. My office is always open. We support staff – we value staff.”

Managers were well thought of by people, their family and staff. Comments from staff included, “[Manager’s Name] is helpful and approachable” and “The manager listens.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

We observed a ‘you said we did’ board which evidenced the changes the provider had put in place in direct response to people’s feedback. For example, people had requested more animal visits to the home, and this had happened.

‘Whispering Wednesdays’ were held weekly, which provided people with the opportunity to meet and discuss any changes they would like to make or issues they wished to discuss.

Staff told us they were confident to speak up and felt they were listened to, one member of staff told us, “The managers do listen, I made a recommendation that [Name] needed their nails cutting, this was done when I next came in.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed some staff from overseas. Processes were in place to help ensure staff felt supported not just in the workplace but in their domestic life too.

Although we were assured the provider had clear responsibilities, roles, systems of accountability and good governance and acted on the best information about risk, performance and outcomes, further time was required to ensure that improved practices were sustainable and embedded.

A new manager had been appointed since our last inspection. The manager was also supported with the day to day running of the home by a deputy. At the time of our assessment, the manager had submitted their application to CQC to become registered.

The manager had overhauled governance processes since the last inspection to help improve oversight of the service.

Where audits had highlighted shortfalls in practice, there were actions in place to help resolve any issues. However, we observed not all actions had been assigned to a responsible person meaning it was difficult to track if the action had been completed. For example, as part of a dignity audit, a lack of condiments had been repeated as an action for the last 2 months. We spoke with the manager about this who confirmed they would add this information moving forward.

We also observed issues with hygiene in the kitchens which had not been actioned in a timely enough way.

Governance processes helped to deliver good quality, sustainable care, treatment and support, and ensured the provider had an up-to-date picture of risk across the service.

Although some improvements were yet to be made, for example, to the environment to help better meet the needs of people living with dementia, there was an action plan in place, with timescales.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

For example, the provider had achieved the gold standard in the 6 steps programme which was designed to offer high standards for end-of-life care and support.

People’s care records evidenced appropriate partnership working with external agencies, for example, in relation to managing people’s nutritional requirements and skin integrity needs.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcomes and quality of life for people. They actively contributed to safe, effective practice and research.

The provider demonstrated they were focused on learning and improving by responding positively to our findings at the last inspection and had worked hard to make changes driven to better improve the standards of care for people.

We saw how the provider had sought out and engaged with external professionals to seek support on how to make positive changes to the environment to better meet the needs of people living with dementia. The provider was also in the process of implementing sensor technology to help reduce the risk of falls.