• Care Home
  • Care home

Stepping Stones

Overall: Requires improvement read more about inspection ratings

1-6 Boxhill Close, Honicknowle, Plymouth, Devon, PL5 3QB (01752) 788273

Provided and run by:
Matthew & Michael Healthcare Ltd

All Inspections

30 May 2023

During a routine inspection

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.

About the service

Stepping Stones is a residential care home that provides personal care and support for up to 15 people with a learning disability, autism or who have complex needs associated with their mental health. At the time of the inspection there were 14 people living at the service.

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

Right Support:

People were not always supported to have maximum choice and control of their lives and staff were not always supporting people in the least restrictive way possible. The service could not always demonstrate they were acting in people’s best interests.

People had fulfilling days and staff supported people by focussing on their strengths and encouraging people to be independent. People were supported to receive specialist health and social care support locally in line with their assessed needs. The service was homely, clean and people's bedrooms were personalised.

Right Care:

Staff respected the people they supported and provided care that was caring and compassionate. People were encouraged to take positive risks to enhance their wellbeing and support plans reflected their individual needs and preferences.

Right Culture:

The ethos, values and attitudes of staff helped to ensure people using the service were enabled to lead confident, inclusive, and empowered lives. Staff understood their role in making sure that people were always put first, and their care and support was tailored to their individual needs and preferences.

People knew how to make a complaint and felt confident they would be listened to if they needed to raise concerns. The management team had created an open and transparent culture, where constructive feedback was encouraged.

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 7 November 2019). The service remains rated requires improvement. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

This service has been rated requires improvement for the last three consecutive inspections. You can see what action we have asked the provider to take at the end of this full report.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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 have identified breaches in relation to safe care and treatment, need for consent, deprivation of liberty safeguards (DoLS), recruitment and good governance. We have also made recommendations in relation to staffing levels and accessibility of information. 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.

30 September 2019

During a routine inspection

About the service

Stepping Stones is a residential care home that provides accommodation and personal care for up to fifteen people with a physical disability. Some people may also have some learning difficulties.The care home is located on one site but split across two bungalows and three self-contained flats.

The service was registered for the support of up to fifteen people. Fourteen people were using the service at the time of the inspection. This is larger than current best practice guidance. However. the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other large domestic homes of a similar size. There were deliberately no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

The Secretary of State has asked the Care Quality Commission (CQC) to conduct a thematic review and to make recommendations about the use of restrictive interventions in settings that provide care for people with or who might have mental health problems, learning disabilities and/or autism. The thematic review looks in-depth at specific issues concerning quality of care across the health and social care sectors. They expand our understanding of both good and poor practice and of the potential drivers for improvement.

As part of the thematic review, we carried out a survey with the registered manager at this inspection. This considered whether the service used any restrictive intervention practices (restraint, seclusion, and segregation) when supporting people.

The service used some restrictive intervention practices as a last resort, in a person-centred way, in line with positive behaviour support principles.

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

The management of incidents was not always consistent. The provider had taken action to safeguard people when incidents/allegations had occurred, but had not in all cases informed other agencies in line with safeguarding procedures. This could mean that people would not be fully protected from the risk of harm/abuse. We found no evidence that people had been harmed and the provider responded promptly by liaising with the local authority in relation to gaps we found and by also reviewing their incident and reporting procedures.

We found improvements had been made in the overall running of the service and audits were more robust. However, they failed to pick up the issues we identified on inspection in relation to incidents. Improvements and processes to ensure people continued to receive a safe and good quality service needed further embedding. Improvements were still needed in relation to personalised care planning and the environment to ensure people’s dignity and independence was maintained. The provider had an action plan in place to address these areas and had shared this with us.

We found the overall culture of the service had improved. People, relatives and other agencies said people were more involved in decisions about their care, had more opportunities and their rights and independence were being promoted. The provider and registered manager understood their roles and responsibilities, and talked about improvement in staff training, recruitment, supervision and oversight to ensure improvements in culture and practice were embedded and sustained.

Healthcare professionals told us communication had improved and the culture of the service was more open and positive. People’s health and dietary needs were understood and met.

People told us staff were caring and respected their privacy and independence. People said the overall care and support they received had improved since the last inspection and since the new registered manager had been appointed.

Improvements had been made to the environment and an action plan was in place for further improvement to bathrooms and accessibility.

Staff knew people well, and said they felt well supported by the registered manager and provider.

The registered manager had worked hard to address concerns raised at the previous inspection. They had developed good relationships with local professionals and attended a range of forums in relation to best practice and service improvement.

We saw lots of improvements since we last inspected six months ago. However, we did identify one new breach and one repeated breach of the regulations regarding safeguarding people and good governance. We made one recommendation in relation to the environment.

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 Inadequate (published 19 April 2019) As part of our enforcement action a condition was placed on the providers registration, which required them to send us monthly reports outlining the action taken and planned to meet the regulations and address the concerns found. At this inspection enough, improvement had not been made/sustained, and the provider was still in breach of regulations. The rating of the service for this inspection is requires improvement.

This service has been in Special Measures since April 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating and to follow up on action we told the provider to take at the last inspection.

Enforcement

We have identified breaches in relation to safeguarding people from abuse and improper treatment and good governance. 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 for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

26 February 2019

During a routine inspection

About the service: Stepping Stones is a residential care home that provides accommodation and personal care for up to 15 people with a physical disability. Some people may also have some learning difficulties. These needs may or may not be associated with their physical disability. The care home is located on one site, but split across two bungalows and three individual flats. On the day of the inspection 14 people were living at the service.

People’s experience of using this service:

• People who had lived in the service for many years mainly said they were happy. People commented about aspects of the environment, and said they wished some things could be better. People spoke in a way that suggested they had accepted aspects of their care and did not know to question anything different. For example, one person had no lampshade and just a light bulb in the centre of their room. They said it had been like it for a long time, but they said they would like to have a lampshade. People did say there had been improvements since the new registered manager had started working in the home.

• Risks in relation to people’s care and lifestyle were not assessed, understood and managed in a way that kept them safe. Some practices in relation to risk did not protect people’s human rights.

• People did not live in an environment that was well-maintained or promoted their dignity and independence.

• People’s rights in relation to their capacity had not been fully understood and respected. Correct processes had not always been followed when people lacked ability to make decisions about their care.

• Risks and needs in relation to people’s physical and mental health had not in all cases been consistently understood and supported.

• The culture of the service did not always respect and promote people’s rights, dignity and independence.

• The leadership and auditing of the service had not been robust and had failed to identify the concerns we found in relation to practice, the environment and culture of the service. This meant that people had continued to receive a service that was not fully safe, effective, caring or responsive to their needs.

• The provider had failed to act on some areas of concerns found at the last inspection. Although some improvements had started and were planned, it was not possible to see the impact this would have on people or if these improvements would be sustained.

• The service is now judged to be inadequate in keeping people safe, providing effective care and being inadequately well-led.

Rating at last inspection: The rating at the last inspection was Requires improvement overall. (The report was published on the 27 April 2018)

Why we inspected: We inspected in line with our inspection methodology. This was within 12 months of publication as the service had been judged to be requires improvement in safe, effective, caring, responsive and well-led at the last inspection.

Enforcement

At our last inspection we told the provider to provide us with an action plan about how they would ensure compliance with the regulations and by when. At this inspection we found action had not been taken to address all the concerns and breaches of regulations found at the previous inspection.

We have made a recommendation about the management of medicines, accessible information, fire safety, and end of life care.

In respect of this inspection, full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Follow up:

Following the inspection we spoke to Plymouth City Council about our initial findings and practices we had concerns about.

The overall rating for this registered provider is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. We will have contact with the provider and registered manager following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

15 March 2018

During a routine inspection

We carried out an unannounced comprehensive inspection on 15 and 20 March 2018.

Stepping Stones is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home provides accommodation and personal care for up to 15 younger adults who have a learning and/or physical disability. The care home is located on one site, but split across two care homes (Bungalows) both accommodating six people, as well as three individual flats. On the day of the inspection 15 people were living at the service.

The service had a registered manager however they had not been working since September 2017. In their absence, the provider had put an acting manager in charge of the day to day running of 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 person's'. 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. However, in line with their provider’s legal obligations, they had failed to inform the Commission of the registered manager’s long term absence. Following our inspection the provider apologised and promptly submitted the relevant notification. They told us they now understood the process and would ensure this did not happen again.

During our discussions with people, they provided hesitant and apologetic responses to questions asked about the service, and one person told us they did not always feel confident to raise concerns, therefore we made a safeguarding alert to the local authority adult safeguarding team, to ensure people were fully protected.

Overall, risks associated with people’s care had been documented to help ensure people’s needs were known and met safely by staff. However, risks associated with one person’s care had recently changed and whilst a new risk plan had been put into place, it was not being correctly followed by staff. This meant the person was at risk of receiving inconsistent care that did not meet their current needs.

People told us there were not always enough staff to meet their needs. Comments included, “They need more staff, there aren’t enough”, and “If I call in the morning when handover is going on I am told to wait”. Relatives told us they did not feel there was enough staff to ensure people were supported with independent living skills, and to promote and deliver opportunities for social engagement. Staff also told us they were unable to effectively promote people’s independence, because they did not feel there was enough staff. They told us, “We could do a whole lot more, if we had more staff” and “There aren’t enough of us”.

Overall, people received their medicines safely. A medicine audit was in place to help monitor medicine practices and identify where improvements were required, however this had not been carried out since September 2017, therefore had not identified current issues requiring attention.

People were assisted with their mobility, by the use of moving and handling equipment, such as hoists. To ensure people’s safety, staff had received training. However, one person told us their sling for the hoist cut into their groin and it hurt, they told us staff, were looking into this. However, when we told the acting manager they had not been made aware and the sling was still being used.

People lived in a service whereby the temperature was not monitored to ensure it met with people’s preferences. Whilst people did not complain to us or staff, during our inspection communal areas and bedrooms were not always warm. One relative told us they had also complained about the temperature of the service but no action had been taken to monitor temperatures.

Staff had undertaken training the provider had deemed as ‘mandatory’. However, training specific to people’s needs had not been completed. For example, staff had not been trained to support people with physical or learning disabilities. People living with complex communication needs, relied on staff ‘getting to know’ them, rather than staff undertaking relevant training. New staff joining the service received an induction to help introduce them to the provider’s policy and procedures. Staff meetings had recently started to take place, but regular one to one supervision of staff practice and appraisals of performance had lapsed. Despite this, staff told us they felt supported.

People were not always empowered by the design, adaptation and decoration of the service. The environment was tired. Door frames and walls were scuffed, paint was peeling off walls and a lock on a bathroom did not work. Lounge areas did not always have sofas or chairs for people to sit on, if they chose to not be in their wheelchair. The provider told us, there was a refurbishment plan in place, with two new kitchens being fitted in the summer. Some bedrooms had also been re-decorated and radiators replaced.

People were supported to have a balanced diet, and live a healthy life. People were encouraged to eat fresh fruit and vegetables and had independent access to drinks and snacks. People helped with the preparation of meals, such as peeling and chopping vegetables. However, the menu was typed, which did not take into consideration people’s individual communication needs.

People were not always respected and supported by compassionate staff. There was limited fun and uplifting conversation between people and staff, and on four occasions during our inspection people were ignored by staff as they walked through the lounge. Staff, were observed to be focused on completing tasks, such as washing and cleaning, rather than engaging with people.

The provider’s philosophy was based on empowering people to become independent to enable then to move from residential care to living independently, however people’s support plans did not detail how people could achieve this and gain confidence and skills, and staff told us they did not always have time to spend with people to enable this to happen.

People were involved in decisions relating to their health and social wellbeing, but one relative told us they were not always kept updated when their loved one had attended healthcare appointments.

People’s bedrooms were individually personalised, and their families and friends were welcome to visit at any time. People’s support plans provided good detail about how people wanted their privacy and dignity to be maintained, but staff did not always knock on people’s bedroom doors, prior to entering.

People told us there was not enough to do, and that they sometimes felt bored. Comments included, “There are not enough activities, I want to go out more, go to the cinema…do some cooking”, “I don’t want to sit around and be bored all the time” and “I want more things to do”. Relatives also told us they did not feel there was enough socially for people to do.

People had support plans in place, which were detailed about how their needs should be met. Support plans were reviewed annually, or as required. Relatives told us they had not always been involved in the review of their loved ones support plan, to help ensure it met with their needs and wishes. People’s support plans did not detail what their aims and goals were for now and for the future. This meant people did not have a focus to be motivated by. People’s cultural and spiritual needs were not documented to enable them to be known, and therefore met.

One relative told us they did not feel that people’s personal care was always managed effectively, and told us when they arrived sometimes their loved one looked dishevelled. Commenting, “They need more help with their personal care, it all depends who gets [person’s name] up”.

Overall, people’s concerns and complaints were listened to and used to help improve the service. However, one relative told us how they had made small comments about things which needed addressing, however no action had been taken, so they had to make a formal complaint. People had received a copy of the complaints procedure however it was only available in a written format, which meant it may not have been suitable for everyone to understand.

The provider had met with people and staff to inform them about the interim management arrangements. Overall, people, staff and relatives told us the acting manager had the skills to manage the service. The acting manager told us, they felt well supported by the provider who visited most months, and was available by phone on a daily basis.

People lived in a service, which was not effectively assessed or monitored by the provider, to ensure its ongoing safety and quality, because the provider was not aware of their responsibilities.

There were some quality checks in place, however these had not been completed since the absence of the registered manager. People’s confidential information was not always kept securely in line with the Data Protection Act 1995.

People lived in an environment which did not always have a positive and inclusive culture. The atmosphere within the service was based on the completion of tasks, rather than focusing on people. The provider’s ethos of promoting people’s independence was not embedded into staff practice. Leadership, direction and positive role modelling within the service was absent, which resulted in people not always being empowered and motivated to live fulfilled lives.

People did not live in a service where there was continuous learning taking place to help facilitate improvement. The provider or staff did not attend any other forums or conferences, to help discuss best practice with regard to how to support people effectively and to help ensure the ongoing and su

9 and 10 December 2015

During a routine inspection

The inspection took place on the 9th and 10th December 2015 and was unannounced.

Stepping Stones is a residential care home providing care and accommodation for up to 15 people. On the day of the inspection 15 people were using the service. Stepping Stones provides care for people with a learning disability and people with physical disabilities.

The service had a registered manager in post. 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.

During the inspection people and staff were relaxed; the environment was clean and clutter free. There was a happy, calm and pleasant atmosphere. People confirmed staff were kind to them and told us “Very caring, they ask me what I want to do”; “They are kind and caring, no problems with the staff, they are gentle and make me laugh, they spend time talking to me, play games with me.”

Care records were focused on giving people control and encouraging people to maintain their independence. People and those who mattered to them were involved in identifying people’s needs and how they would like to be supported. People preferences were sought and respected. People’s life histories, disabilities and abilities were taken into account, communicated and recorded, so staff provided consistent personalised care, treatment and support.

People’s risks were known, monitored and managed well. There was an open, transparent culture and good communication within the staff team. Accidents and incidents were recorded and managed promptly. Staff knew how to respond in a fire and emergency situation. There were effective quality assurance systems in place. Incidents related to people’s behaviour were appropriately recorded and analysed to understand possible triggers and reduce the likelihood of a reoccurrence.

People were encouraged to live active lives and were supported to participate in community life where possible. Activities were meaningful and reflected people’s interests and individual hobbies for example football, theatre trips and shopping outings. People also enjoyed activities within the home such as arts and crafts and board games.

People had their medicines managed safely. People received their medicines as prescribed, received them on time and understood what they were for where possible. People were supported to maintain good health through regular visits with healthcare professionals, such as GPs and dentists and the specialists involved in their specific health care needs.

People and staff were encouraged to be involved in regular meetings held at the home to help drive continuous improvement. Listening to feedback helped ensure positive progress was made in the delivery of care and support provided by the home.

People knew how to raise concerns and make complaints. People and those who mattered to them explained there was an open door policy and staff always listened and were approachable. People told us they did not have any current concerns but any previous, minor feedback given to staff or the registered manager had been dealt with promptly and satisfactorily. Any complaints made would be thoroughly investigated and recorded in line with Stepping Stones own policy.

People told us they felt safe and secure. People’s personal possessions and their money was kept safely. Comments included, “Yeah, they help you; they make sure I’m safe – check my wheelchair is working, I’m wearing my belt”; “I have my own bank account, my card is kept safely in the office and I can have it whenever I want.”

Staff understood their role with regards the ensuring people’s human rights and legal rights were respected. For example, the Mental Capacity Act (2005) (MCA) and the associated Deprivation of Liberty Safeguards (DoLS) were understood by staff. All staff had undertaken training on safeguarding adults from abuse; they displayed good knowledge on how to report any concerns and described what action they would take to protect people against harm. Staff told us they felt confident any incidents or allegations would be fully investigated.

Staff received a comprehensive induction programme specific to Stepping Stones and the Care Certificate (a new staff induction programme) had been implemented within the home. There were sufficient staff to meet people’s needs. Staff were very kind, caring and thoughtful. Staff ensured people mattered and cared for people’s families and relatives. Staff were appropriately trained and had the correct skills to carry out their roles effectively.

Staff described the management as open, very supportive and approachable. Staff felt like part of a large family and talked positively about their jobs. Comments included “X is always positive, well organised, our ideas are listened to; and “There is always someone to go to.”

10, 22 September 2014

During an inspection in response to concerns

One adult social care inspector carried out this inspection. 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 people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

We had received some concerns prior to our inspection relating to the care of people living at Stepping Stones. We found no evidence to support these concerns.

Is the service safe?

People told us they felt "safe"; "staff are kind, they help me when I need help, I feel safe";"I feel safe and cared for, I will talk to the staff if I'm worried"; "I'm happy living here, I feel safe."

Records showed that people's needs and risks had been identified and planned for. A range of risk assessments had been completed including those for pressure areas, nutrition and moving and handling. We saw that good directions had been given to staff on how people's needs should be met.

We saw that people were protected from the risk of abuse because reasonable steps had been taken to identify the possibility of abuse and to prevent abuse. For example, there were policies and procedures in place for staff to follow if they suspected abuse had occurred. People appeared relaxed and comfortable in their interactions with staff. All staff had received training in safeguarding vulnerable adults from abuse.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, proper policies and procedures were in place and the Registered Manager understood how to submit an application if one were required.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well. One person told us 'Staff are very good, they look after me very well'. Staff had received training to meet the needs of the people living at the home.

There were arrangements in place to deal with foreseeable emergencies. For example, the files we looked at contained Personal Emergency Evacuation Plans (PEEPS). This meant that staff had access to the information they would need if an evacuation of the premises was needed.

Is the service caring?

People were supported by kind and attentive staff. We saw and heard positive interactions between staff and people who lived at the home. Any directions that were given to people were done so in a sensitive and discreet manner. During our visit we heard staff speaking with people in a respectful and caring way. We saw staff interacting with the people they supported and providing opportunities for people to talk with them. We also saw that staff were friendly and patient in their approach.

Is the service responsive?

People living at the home and their representatives had been asked for their views on the quality of care provided. If people required external health professionals to support their health needs we saw referrals had been made promptly. We spoke with the local learning disability service as part of this inspection, Healthwatch and the advocacy service. The provider was working with these agencies to support people's multiple needs.

Is the service well-led?

We found the Registered Manager had good systems in place to monitor the quality of service provision. We saw evidence of regular health and safety checks on equipment and audits covering all aspects of people's care including medicine audits. Incidents at the home which occurred were documented and analysed for trends to prevent a reoccurrence. Complaints were listened to, investigated and responded to within the home's policy timeframes.