Stepping Stones

Stepping Stones is a residential care home providing care to 32 people at the time of the inspection. There are 8 different households set in 4.5 acres that can support up to 33 people living with a learning disability or autistic spectrum disorder.

People living at Stepping Stones have access on site to an art room, a music room, a gym and a sensory room as well as an outdoor swimming pool.

People’s experience of using this service and what we found

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Based on our review of key questions of safe, responsive and well-led, the service was not always able to fully demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

The manager and provider had implemented new monitoring systems to continue to improve the quality of the service people received. However, more time was needed to allow these systems to bring about and sustain individualised outcomes for all people. In addition, some of the systems were not always effective or audited to ensure they picked up the concerns we identified during the inspection.

Right support

People were supported by staff who understood their care and support needs, and what was important to them.

Since our last inspection progress has been made in ensuring people were being supported to start accessing the community again post COVID-19 to enjoy activities and outings. Staff knew people well, however people were not always supported to identify and achieve their aspirations and goals.

People were supported to access specialist health care services and maintain contact with their families.

Right care

People's risks were identified and managed by staff. People's care records reflected their emotional and health needs and progress has been made in identifying shortfalls in people’s care records and updating these. However, some support plans still lacked comprehensive individualised details about people’s social and leisure/occupational aspirations and how they wanted to be supported to achieve this. Further time and development were needed to demonstrate that people's lives were enriched by a service that focused on their wishes, needs and rights.

Right culture

Staff had positive relationships with people and their relatives. There was visible leadership and management of the service and the registered manager’s vision was “to give people who live here a voice.”

The model of care being provided at Stepping Stones did not always maximise people's choice, control and independence. The provider had identified areas that required improvement and was working on their service improvement plan. However further time was needed to enable the provider and management team to demonstrate how the improvements being made would enhance people's quality of life and well-being for all people living at Stepping Stones such as empowering people to live a life of their choice.

The provider recognised that their values and the principles of Right support, right care, right culture guidance still needed to be fully understood and embedded into staff practices to ensure people were explicitly supported to live a fulfilled life.

People’s relatives told us that their loved ones felt safe living at Stepping Stones.

People’s personal risks had been identified and assessed which gave staff guidance on how they should support and monitor people to reduce their individual risks. Risks relating to the environment were now assessed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 16 June 2022).

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 6 May 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, person centred care and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. We also received information of concern in relation to people's care since our last inspection.

This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.

For the key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service remains requires improvement. This is based on the findings of this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Stepping Stones on our website at www.cqc.org.uk

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified a breach in relation to person centred care at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Stepping Stones is a residential care home providing personal care to 32 people at the time of the inspection. There are eight different houses set in in 4.5 acres that can support up to 33 people living with a learning disability or autistic spectrum disorder.

People’s experience of using this service and what we found

The management of people’s risk had been assessed and were known by staff, however identified strategies used to support people to mitigate their risks such as risk of choking had not been assessed by specialist professionals.

The provider’s own quality assurance systems had not been effective in identifying gaps in fire drills, water checks, recruitment records, people’s risk management plans and notifications. The provider could not always be assured that infection control practices were being maintained as their auditing systems did not reflect recognised COVID-19 control measures.

The service supported people to review their medicines prescriptions and to help reduce the risk of overuse of unnecessary medicines although we found some improvements to medicine management were needed.

The provider continued to actively recruit staff to vacancies. We made a recommendation to support robust recording of pre-employment checks undertaken.

Systems were in place to protect people from harm and abuse. Progress was being made in ensuring all staff had the skills to carry out their role. Staff told us they felt supported but reported that communication needed to improve. This was also reflected in some health care professional’s feedback about the service. We have made a recommendation to support the improvement of external incident reporting.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Based on our review of key questions of safe and well-led, the service was not able to fully demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Right support

People were supported by staff who understood their care and support needs, and what was important to them.

Although staff knew people well, people were not continually supported to achieve their aspirations and goals. People were not always supported to have maximum choice and control over their lives. There was slow progress in ensuring people were being supported to follow their interests and goals now that the COVID-19 restrictions have been eased.

People were supported to access specialist health care services and maintain contact with their families.

Right care

People’s risks were identified and managed well by staff. People's care records reflected their emotional and health needs but lacked details about their social and leisure/occupational aspirations and how they wanted to be supported to achieve this. Further development was needed to demonstrate that people’s lives were enriched by a service that focused on their wishes, needs and rights.

Health care professionals praised the service and how they had supported people through the pandemic.

Right culture

Staff had positive relationships with people and their relatives. There was visible interim leadership and management of the service in the absence of a registered manager.

The model of care being provided at Stepping Stones did not fully maximise people’s choice, control and independence. The provider had identified areas that required improvement and was working on their recovery plan to address the impact of the COVID-19 restrictions. However further time was needed to enable the provider and management team to demonstrate how the improvements being made would enhance people’s quality of life and well-being for all people living at Stepping Stones such as empowering people to live a life of their choice.

The provider recognised that their values and the principles of Right support, right care, right culture guidance needed to be fully understood and embedded into staff practices to ensure people were explicitly supported to live a fulfilled life.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good.

Why we inspected

We received concerns in relation to staffing levels and the management of people’s medicines. As a result, we undertook a focused inspection to review the key questions of safe and well-led only and to assess that the service is applying the principles of Right support, right care, right culture guidance.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvement. Please see the safe and Well Led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Stepping Stones on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to person centred care, people’s safety and the provider’s monitoring systems at this inspection.

We made two recommendations regarding pre-employment check recording and incident notification to support improvement.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published and request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

People’s experience of using this service: Audits and quality checks supported the registered manager to identify areas where the service needed improvement. However, these quality monitoring systems were not always effective in identifying all shortfalls in the service provided. Although the provider had implemented improvements to their quality monitoring promptly we could not judge at this inspection whether these changes would be effective in all shortfalls being identified and addressed. The provider needed to complete their planned actions to avoid breaching a legal requirement in future and to improve the service. We have therefore rated the key question ‘Is the service Well-led?’ as requires improvement.

We found improvements to staff recruitment procedures and the management of infection control in laundry rooms.

People were safeguarded from the risk of abuse and from risks from receiving care. People were supported by sufficient numbers of staff.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

Staff received support to develop knowledge and skills for their role. There were arrangements in place for people and their representatives to raise concerns about the service.

People's individual needs and wishes were known to staff who had achieved positive relationships with them. People and their representatives were involved in the planning and review of their care. People were supported to maintain contact with their relatives.

People were treated with respect and kindness and their privacy and dignity was upheld, they were supported to maintain their independence as much as possible. People and their representatives were involved in the planning and review of their care and people took part in a range of activities.

The management were visible and accessible to people and their visitors.

The outcomes for people using the service reflected the principles and values of Registering the Right Support in the following ways, promotion of choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

Rating at last inspection: At our previous inspection the service was rated good (last report was published on 26 November 2016). At this inspection the rating for this service remains as good.

Why we inspected: This was a planned inspection based on the previous rating at the last inspection.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Stepping Stones is a care home for 33 people with learning disabilities. Accommodation is provided in a number of houses and bungalows on one site. At the time of our inspection there were 32 people being supported by the service.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We received positive feedback from people using the service and health and social care professionals. One person told us “This is the best place I’ve ever been in”. A health care professional stated “I have had no concerns about the care (the person) receives”. A social care professional told us “They do a good job and work as a team”.

People were at risk of receiving care from unsuitable staff because robust recruitment procedures were not always being applied. Medicines were generally managed safely although medicine storage temperatures needed more closely monitoring in two areas. Some laundry rooms needed improvement to ensure people were protected by robust infection control procedures.

People were treated with respect and kindness and their privacy and dignity was upheld, they were supported to maintain their independence as much as possible. People and their representatives were involved in the planning and review of their care and people took part in a range of activities.

Staff received support to develop knowledge and skills for their role. They spoke positively about their work with people. The registered manager was visible and accessible to people and staff.

Systems were in place to check the quality of the service provided.

This inspection was completed by two adult social care inspectors and a pharmacy inspector. We spoke with seven people who used the service, but because of their complex needs, they were not able to tell us about their experiences in any detail. Hence we used a number of different methods to help us understand the experiences of people using the service. This included observing staff as they supported people living at Stepping Stones. We spoke with five members of the management team, including the registered manager and nine care staff. We reviewed five care records, 12 medicine administration records, incident and audit records. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what representatives of people using the service and the staff told us, what we observed and the records we looked at.

Is the service safe?

People were safe because risks were assessed and managed effectively. Risk assessments had been carried out and were updated regularly to ensure risks to people were managed. Clear guidance suggesting how staff should react to support people to become calm was available to staff. This included how to keep people safe and when to consider use of ‘as required’ medicine. We observed staff supporting people when upset and saw they followed the guidance in care plans to help people become calm. For example, distracting the person by offering an activity they enjoyed or taking them out for a walk.

The policies and procedures in place to safeguard people from abuse were robust and the provider followed local and national reporting requirements. We spoke with six staff members about their role in safeguarding. During these conversations, staff demonstrated they knew how to recognise abuse, how to respond and they understood their responsibility to protect vulnerable people. This meant people were protected from abuse as staff and people had been enabled to raise concerns and the provider worked with external agencies to keep people safe.

The systems in place to manage people’s medicines were safe. This included appropriate staff training and checks. The checks carried out ensured that any shortfalls could be identified and managed promptly.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff were trained to understand when an application should be made and how to submit one.

Is the service effective?

The service people received was effective because their individual needs, choices and preferences were reflected in their care plans. People were supported to access a range of activities within their local community. For example, they told us they enjoyed going out to local shops and pubs, to play pool and to shop or have a drink.

People were supported by staff who understood how to meet their needs. Staff were provided with training and support which enabled them to understand how to support people’s care and specialist needs.

Staff worked with others, including external health professionals, to ensure people's health and welfare needs were met. There was evidence that people were supported to attend regular health checks with their GP, dentist, optician and chiropodist. Information about people’s health and treatment had been documented so this could be shared with health professionals when needed, including in an emergency.

Is the service caring?

The service was caring because people and their representatives had been enabled to express their views about what was important to them and they had been listened to. People’s care plans described their likes, dislikes and any routines that were important to them. Where people had particular needs or preferences about the way they were supported, these had been identified.

Is the service responsive?

The service was responsive because when people’s needs changed appropriate action was taken. There was evidence that care plans and risk assessments had been updated to reflect changes in people’s needs. Staff told us care plans were also reviewed annually with people and others involved in their care, such as their family or social workers. Some people had signed their care records to confirm they had been involved in their care reviews. We found care records identified where other records should be read alongside them, such as behaviour and mood escalation plans and communication plans. This meant staff had access to relevant and up-to-date information about each person’s needs.

Is the service well-led?

The service was well-led because effective quality assurance processes were in place and where the need for improvement had been identified, timely action had been taken. The provider was proactive in identifying shortfalls within the running and management of the service and in obtaining relevant professional advice. The provider was open and transparent when responding to our information requests and involved other external agencies when this was appropriate.

Staff were clear about their roles and responsibilities. They felt well supported and were confident that if they raised any issues or concerns, these would be managed effectively. People, or their representatives, met with staff regularly to give feedback about the service provided.

We looked at the care records for seven people and spoke to ten people who used the service. People were positive about the care and the support they received from the staff. They told us that their dignity and privacy was respected and that staff were polite and caring in their approach. People we spoke with said they were assisted to be as independent as they wished to be. One person told us, "staff are very helpful".

We also spoke to the manager and staff. The care and health records were seen to be detailed and comprehensive. They provided staff with the personalised information needed to support people effectively.

People were supported by a well led staff team, who were suitably trained and supervised, to ensure good care practice. People received appropriate care and support to meet their individual needs. We saw the interaction between the staff and people living at the home to be friendly, supportive and geared to each person as an individual. Staff were encouraged to obtain further qualifications and were trained in subjects relevant to people's needs.

We looked at the care records for six people and spoke to two people who used the service. The care records were individual to each person and we found them to be up to date and accurate. The health action plans contained detailed needs for each person. Each person had an activity plan in place and the care plan and daily notes reflected these activities. Care plans and risk assessments were found to be person centred. These were also found to be up to date and reviewed regularly. Care plans were available in pictorial form and where necessary details of the person's advocate were documented. We saw evidence that the care plans had been written with the person themselves where it was appropriate to do so.

We spoke to two people who used the service. One person told us 'I like living here because I like to do my own thing, but staff are here if I need help'. Another person told us 'I have been here seven years and I have my privacy and can do my hobbies. I have lots to do and like it here'.