Stepping Stones Red Marley

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 Good. At this assessment the rating has remained Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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.

Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service. One staff member told us, “It’s treated like a home, it’s not like a hospital, people are made to feel welcome, they live how they want to live, they build bridges and friendships, and we build them up.”

The registered manager demonstrated good awareness in monitoring the culture of the home saying it was about, “Being open and giving time so they are listened too. Being honest and people aren’t always right or wrong and my role is to mediate some of that. I recognise we have robust residents, and we need robust staff and with this comes opinions and this needs support and that’s my role. People need to come and vent, and it may just that and other times I need to step in.”

We found there was a positive approach to ensuring continuous development of the service. There was a range of policies and procedures to guide staff on what was expected of them in their roles.

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.

The registered manager demonstrated good knowledge and insight into people’s needs that the service supported. They were able to fluently talk about individuals and what mattered to them and how they presented in certain situations. There was a clear passion from the registered manager in supporting people with complex mental health and learning disability needs.

The registered manager told us that they had the opportunity to keep their skills and knowledge up to date saying, “I have had opportunity to do some bits around personality disorders. One training session was two days with some amazing speakers very beneficial.. I also went on a two-day conference in Manchester for mental health and art therapy and came away so inspired and we do a lot here but my aim here is to have an exhibition somewhere for all their work, and get it seen wider as we display it here.”

People and relatives felt that the home was well managed, and people were familiar with who the registered manager was. Comments included, “Yes. I go to the office. She sometimes comes round” and “I find her very approachable and responsive whenever I call. I've been informed of the recent takeover and reassured that Stepping Stones day-to-day seems unlikely to change.”

Staff spoke highly of the registered manager and her leadership within the home. One staff told us, “I can always talk to her and [administrative staff], they are approachable.” Professionals working with the service praised the registered manager and the way the service was run stating, “[Registered manager] is a wonderful manager, so accommodating and readily available for staff and patients alike, it is abundantly clear she is wholly committed to the service and its users” and “The manager, admin staff and all staff are welcoming, kind and genuinely care for all residents as well as having excellent working relationships with other organisations.”

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

Staff told us they would be confident and wouldn’t hesitate to speak up if they needed to about any concerns. Staff had confidence in the registered manager and that they would take any action where needed. One staff told us, “[Registered manager name] is a strong manager and the team leaders are good, and I can talk to them, and I hope people can feel they can talk to me.”

The provider had a whistle-blowing policy in place, and this recognised that the service supported people who were vulnerable. Staff had heard of the term freedom to speak up saying, “I have heard of this, I would be confident to speak up and not worried that there would be repercussions.”

The registered manager was aware of their responsibilities under the duty of candour and worked in an open and transparent way. The registered manager told us, “We inform families when things happen, we are open with people.”

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 registered manager demonstrated good insight into promoting and supporting a diverse culture of people and staff. We saw that the service had recorded in the provider information return (information that is shared with CQC about the service), that they employed people ranging from 21 to 79 years of age. Staff told us they were given equal opportunities and were treated fairly by their employer. One staff said, “Treated fairly, as a bank worker I feel part of the team even though I am not full time.”

Staff who needed any adjustments were well supported. The registered manager told us, “We are becoming more diverse, not only with people we are looking after but with staff. Previously when I started it was an all-white British culture but now slowly changing, staff are very multicultural, people have to adjust. I did have a staff member who was Muslim, and prayer times were worked around and certain days off for religious beliefs. We did have a Muslim service user who went to their mosque and had certain foods, so we sourced this. No restrictions on recruitment.”

Staff had access to support systems including external counselling, cruse bereavement support and individual agencies available for support if needed.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were clear systems and processes in place to effectively monitor and oversee the service delivered to people. Staff demonstrated good understanding and accountability within their roles. The registered manager undertook regular quality audits across the service which looked at areas including, health and safety, infection prevention control, medicines, staffing and incidents or accidents. Staff from each household completed audits which fed into the managers monthly governance overview. Any outcomes were shared with staff in an action plan to ensure collective responsibility for addressing these in a timely manner.

The registered manager had recently worked on a new format for their walk arounds of the service. We saw this document was clear and focused on positive aspects of ensuring the atmosphere was calm, people were not being rushed, that staff were responding to people’s needs appropriately and people were engaged.

The service had recently been purchased by a new provider. The registered manager spoke positively about this change and how the new provider was bigger and had more resources and support teams that could be drawn upon to effect further changes to the service. The registered manager was in the process of supporting people and staff through this change and reassuring them on any concerns they may have about this integration.

Notifications about events that needed reporting to CQC had been completed and a log kept of these. The rating and report from the last inspection was displayed within the home and on the provider website in line with legal requirements.

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.

The service jointly worked with partners to help drive quality of people’s care and their personal well-being. We gathered feedback from health and social care professionals that worked with the service and received very positive feedback. One professional stated, “I always approach the manager first to arrange a visit, and they arrange to send me the support plans and risk assessments. On the day of the review, I usually speak to the senior staff member on duty. Both have been approachable and helpful and have a good understand of the person I am reviewing.”

The registered manager stated they had formed a good working relationship with health and social care partners and valued their input and support. We saw evidence of information sharing throughout people’s care plans. One professional told us, “Absolutely, staff followed our care-plans when delivering a depot injection, they have accepted and acted upon advice given regarding behaviours and care-plans around vapes and budgeting.”

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

The registered manager was committed to improving the service for people and ensuring the way they worked was effective. One health and social care professional told us, “I have always thought there was a high standard of care, it is difficult to suggest anything they can improve on.”

The registered manager was aware of areas that needed improving and had an action plan in place for the update and redecoration of the service. The registered manager had implemented new documentation including care plans and governance overview which were clear and detailed. There were further improvements they wanted to make but were open in saying that recruitment had slowed some progress saying, “Knock on effect, not giving me flexibility to focus on other things and I’m one person, not having the deputy manager in the office always, has meant I had to choose what to do and things not progressing as I would have liked.”

People and their relatives were mostly positive about the service stating, “Delightful setting and modest scale, supported by the Stepping Stones group.Warm, friendly and well-informed staff…client involvement in simple decisions and activities (e.g. on menus, gardening, outings)” and “The way they look after people and it’s homely.” They noted that improvements were needed in some areas commenting, “I'd like to see more activities on offer within the house”, “Have a coffee shop that we can work in. Have a camp site. Better rooms, more modern rooms” and “Everything takes money. Perhaps more gardening, more enthusiasm about growing things and more trips out.”

Staff told us the service was a good place to work, and they received support and direction from the registered manager. Staff commented, “All staff work together and give people a good quality of life.” and “Everyone is easy to talk to, [registered manager] always has an open door.” Staff did not feel there were many improvements that could be made apart from updating the service and the decoration.