St Stephen's Court

St Stephen’s Court is a residential care home providing accommodation and personal care to people who have acquired brain injuries, neurological conditions, mental health needs and learning and physical disabilities. The service was registered to provide support to up to 30 people. At the time of our inspection 31 people were using the service. One person did move out of the service during our 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.

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

Right Support

The service was registered with CQC prior to the publication of the Right support, right care, right culture guidance. The service was larger than recommended by current best practice guidance. However, the building had been separated into 4 units to provide smaller living accommodation for people. Each unit had a communal area people could access to decide who they wanted to socialise with.

Systems were in place to ensure medicines were managed safely. However, there was excess stock of topical medicines (creams and lotions applied to the skin) for some people. We have made a recommendation about this. Risk assessments were completed to assess known risks people were exposed to and people were encouraged to be as independent as possible. In addition, a range of risk assessments had been completed to assess the safety of the environment.

People were supported to personalise their bedrooms to reflect their taste and preferences and their opinions were sought to ensure people were included in decisions about their care.

Right Care

There were sufficient numbers of staff to meet people's needs. Agency staff were used to ensure safe staffing levels were always maintained. Staff knew people well and care records contained person-centred information to guide staff in how support should be delivered. Information was available to people in alternative formats to support people's communication needs if this was necessary.

Assessments of people's needs had been completed and people were involved in the process. Care plans were in place which detailed how to meet people’s needs.

Staff understood their safeguarding responsibilities. They told us they would be confident in raising any concerns they had and felt confident any issue would be dealt with appropriately.

Right Culture

The management team promoted a positive culture at the service. Managers led by example and advocated staff provided support to people which was person-centred to their individual needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service this practice.

Systems were in place to ensure staff were recruited safely. Most people spoke positively about their relationships with staff. The registered manager was proactive in responding to feedback from people in relation to staffing.

The registered manager worked in an open and transparent way. However, records were not available to demonstrate staff were meeting the requirements of the duty of candour regulation. We have made a recommendation about this.

Systems were in place to review quality and there was a culture of learning from previous incidents to improve performance and staff practices. However, medicines audits did not review all of the medicines which were in use. We have made a recommendation about this.

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 (published 31 March 2020).

Why we inspected

We received concerns in relation to the management of the service and support provided to people. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

Recommendations

We have made recommendations in relation to medicines and duty of candour at this inspection.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

St Stephen’s Court is a residential care home providing accommodation and personal care to people who have acquired brain injuries, neurological conditions, mental health needs and learning and physical disabilities.

The provider was committed to developing the service further to ensure they continue to deliver a service for people in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence.

The service was registered to provide support to up to 30 people and there were 26 people using the service at the time of our inspection. The service is larger than recommended by best practice guidance. However, we have rated this service good because the service was arranged in a way that ensured people received person-centred care and were supported to maximise their independence, choice, control and involvement in the community.

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

People told us they felt safe living at St Stephen’s Court. One person told us, “The staff make you feel safe which is good. Sometimes I feel I can tell the staff my problems and will pull up a chair to chat to them.” Safeguarding policies and procedures were in place and staff understood how to protect people from any form of suspected abuse.

People were supported to have maximum choice and control of their lives and staff assisted them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People’s ability to consent to their care and treatment was assessed. Where people lacked capacity to make a specific decision for themselves best interest’s assessments had been completed. However, the outcome of these decisions were not always recorded. We have made a recommendation about this.

A range of quality assurance systems were in place to monitor quality and drive improvements across the service. The home was clean and a programme of re-decoration was underway. Some furniture and furnishings had been replaced to improve the living environment since our last inspection.

Safe recruitment practices were followed. There were enough staff to meet people’s needs and staff told us they were well supported by the management team. Training relevant to the needs of people was delivered to the staff team. While we found no impact to people, some issues with medicines management were identified. We have made recommendations about these issues.

Assessments of people’s needs were completed. Where risks were identified measures to mitigate known risks were in place. Care and support plans were detailed and contained specific information to guide staff on the actions to take when delivering support.

People were supported to follow their hobbies and interests. A range of meaningful activities were available for people to engage in which were relevant to them. Staff delivered care and support to people specific to their individual needs and preferences.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting 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.

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 inadequate (published 31 October 2019) and there were multiple breaches of regulations. This service has been in Special Measures since 31 October 2019. During this inspection the provider demonstrated that substantial improvements had been made. The service is no longer rated as inadequate overall or in any of the key questions and the provider has achieved compliance with all regulations since the last inspection. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was a planned inspection based on the previous rating to check the actions the provider had taken following our last inspection.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

St Stephen’s Court consists of individual units providing care and support for people who have acquired brain injuries, neurological conditions, mental health needs and learning and physical disabilities. The home can accommodate up to 30 people. There were 30 people living there at the time of our inspection.

The service had not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service did not always receive planned and co-ordinated person-centred support that was appropriate and inclusive for them.

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

The outcomes for people did not fully reflect the principles and values of Registering the Right Support.

Safeguarding policies and procedures were not always followed when safeguarding allegations had been made. People were not consistently supported in the least restrictive way possible. The provider had not notified CQC of all safeguarding incidents in line with legal requirements. These omissions meant that CQC did not have oversight of all safeguarding allegations to make sure that appropriate action had been taken.

Timely action had not been taken to ensure the premises and equipment were well maintained. Some parts of the home were not clean and there were offensive odours in certain areas. Not all of the décor, furniture and furnishings were in a good condition.

Medicines were not always managed safely, and records had not always been completed correctly.

Safe recruitment practices were not always followed. People and staff told us there were not always enough staff deployed to ensure people’s wellbeing and meet their social needs. Some staff were regularly working long hours to cover shifts.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

An effective system to ensure staff were supported was not fully in place. People did not always have choice and control regarding their diet.

Staff were not always proactively engaged with people. They sometimes talked amongst themselves rather than engaging with people. The language used by some staff in care records did not promote people’s dignity.

People were not fully supported to follow their hobbies and interests. Some people told us they were bored and said there was a lack of activities to occupy them. People did not always receive specific care and support to meet their needs and preferences. Staff worked in ways which restricted certain people’s choices.

A complaints procedure was in place. However, records did not always demonstrate that this procedure had been followed.

Serious shortfalls identified at this inspection, had not been identified by the provider's quality assurance system. Management staff had not effectively identified and managed risk therefore, people were placed at risk of harm.

Some staff explained that morale was low at times. They told us that this was due to staffing levels and certain staff not working together as a team.

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 (published 22 June 2018).

Why we inspected

The inspection was carried out due to concerns we received about people’s care. A decision was made for us to inspect and examine those risks.

Enforcement

We identified multiple breaches during the inspection. These related to safeguarding people from the risk of abuse and improper treatment, need for consent, safe care and treatment, dignity and respect, person-centred care, staffing, good governance and fit and proper persons employed. We also identified a breach of Regulation 18 (Notification of other incidents) and Regulation 12 (Statement of purpose) of the Care Quality Commission (Registration) Regulations 2009.

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.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. 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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

St Stephen's Court is a residential care home providing accommodation and nursing care for up to 30 people. 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. At the time of the inspection there were 29 people living at the service.

The service was last inspected in December 2016 when we found one breach of the Health and Social Care Act 2008. This related to Good Governance. At this inspection we found improvements had been made and the provider was no longer in breach of this regulation although further improvements were ongoing.

A registered manager was 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.

At the last inspection we found not all aspects of the service were safe. Our concerns related to safety of the premises, risk assessments and infection control. We also found that not all aspects of the service were well led.

The provider submitted an action plan after the last inspection explaining how they would become compliant. At this inspection we found improvements had been made and the service was now rated good. Individual risks to people were assessed and plans were in place to mitigate these. Visiting professionals were complimentary about the way the registered manager and staff managed risks. They told us security had also improved. Systems for auditing the quality and safety of the service had improved and the registered manager and deputy had a good overview of the service.

Medicines were managed safely and there were suitable procedures in place for the ordering receipt storage and administration of medicines. We found one treatment room was dusty on the first day of the inspection and this was clean and well ordered by the second day. The registered manager told us she would add this to their list of routine checks. The rest of the home was clean and tidy. A small number of rooms had some malodour but this was addressed during the inspection.

Routine safety checks were carried out on the safety of the premises and equipment. This included fire safety checks. The premises were generally clean and tidy and were safe at the time of the inspection although staff reported some delays with repairs. We have made a recommendation about this.

We observed and visiting professionals told us there were suitable numbers of staff on duty. We observed people being cared for at their own pace.

Suitable procedures were in place for the recruitment of staff. Appropriate checks on the suitability of staff to work with vulnerable people were carried out.

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.

The service demonstrated a good understanding of the Mental Capacity Act (2005) and documentation related to this was well maintained. Where people lacked capacity, decisions made in the best interests were appropriately recorded and kept under review.

People’s nutritional needs were met and their nutritional status was monitored and appropriate action taken when necessary. Some people said the menu could be repetitive which we fed back to the provider.

People had access to a variety of health professionals. They told us staff cared well for people, they were contacted for advice in a timely manner and their advice was followed by staff. People were also supported where appropriate to make healthy lifestyle choices.

Staff received regular training, supervision and appraisal. Training considered mandatory by the provider was 100% up to date. Staff told us they felt well supported.

We observed numerous kind and caring interactions between people and staff during the inspection. Professional boundaries were maintained yet staff demonstrated compassion and genuine care for people which we saw was reciprocated by people. People were interested in the inspection process and were keen for the service to do well.

Information was provided to people in a variety of easy read formats and they were supported to communicate their needs and wishes. One person had passed away and the staff sensitively supported people in a celebration of their life and acknowledged the loss while respecting other people’s preference to grieve privately or not to be involved.

Person centred care plans were in place. A new electronic system had been implemented since the last inspection. Care plans we reviewed were detailed and updated regularly. Staff were aware of the content of care plans which was important given the complex needs of some people.

A number of activities were available to people. We saw people taking part in games, one to one activities, baking and singing. A therapy pool and gym was available and trained therapists were employed to support with these activities. We received mixed feedback from people and staff about the range of activities available. Some people said there were insufficient activities outside of one to one time with staff. We have recommended that satisfaction with activities is kept under review in light of these comments.

A complaints procedure was in place. People were aware of how to raise a concern and told us they would always speak with the registered manager and trusted they would be listened to. Information about how to make complaints was displayed and available in different formats.

Audits related to the premises needed to be more robust as the provider had not picked up some of the issues we identified during the inspection. Staff said they felt well supported by the registered manager and a number of visiting professionals spoke highly of the registered manager and staff and about the way the service was run.

Staff told us they would like the senior managers based at head office to be more visible in the service and did not have confidence they had a good understanding of their role and the complexity of the work they did. We have made a recommendation about this.

The provider notified us of incidents and events in line with legal requirements. They were open and transparent in their communication with the Care Quality Commission. Analysis of serious incidents and events involving people took place and the multidisciplinary team, led by the registered manager, reflected upon practice and ensured any lessons were learned and that staff were well supported.

St Stephen's Court is a residential care home providing accommodation and nursing care for up to 30 people. Care is provided for people with learning, neurological and physical disabilities. At the time of the inspection there were 29 people living at the service.

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.

The service had not identified a number of issues in checks and audits which we found at inspection. These related to hygiene and maintenance of key areas of the home.

The service was not operating in line with its statement of purpose and public website. They were not running as five specialist units, but as two larger units with a varied mixture of staffing and people’s needs. The registered manager agreed to review how the service and staff was managed to support differing needs and capacity support requirements of people using the service. Staffing levels were appropriate, but the levels of staff turnover and absence meant that staffing deployment required daily management support. Staff were recruited safely and nursing staff were supported in helping people with complex support needs, including medicines.

Staff morale had been identified for an area of improvement by the provider. An action plan had been drafted for completion in mid-2016, but to date no effective action had been taken. Staff told us they felt this was the major issue holding back the service. The provider told us about their plans to improve staff morale and reduce staff turnover in future.

Some staff training to use the hydrotherapy pool was not kept up to date as staff left, resulting in people being unable to use this part of the service. We have made a recommendation in respect of this.

People care plans had been updated and the service has implemented a person centred approach when planning the delivery of care. Care plans were detailed and described what people's complex support needs were. People told us they felt involved in their care and its review. Where people lacked capacity we saw that best interest’s decisions had been made in line with the requirements of the Mental Capacity Act.

People felt the service offered to them was caring and supported them to achieve their personal goals and ambitions. We saw that staff supported people to maintain their dignity and privacy, as well as to develop skills and personal interests.

The provider’s response to some on going and low level complaints and issues was not consistent. Some issues were not being effectively managed or feedback given to people who raised issues.

The service had offered an innovative and popular activity making a summerhouse, and they planned to build on this in the future. People were supported to access activities or develop their self-care skills. The service had facilities to support this.

Improvements had been made to the service delivery since our last inspection, but identified improvements around hygiene practice, had not been embedded by the provider. Action had not been taken promptly to resolve these issues.

The registered manager and deputy manager were visible to people, staff and external professionals and we were told they were thought of as caring and skilled in supporting people. The service had supported a number of people to regain their independence for example by moving to less structured environments.

St Stephen's Court is a residential care home providing accommodation and nursing care for up to 30 people. Care is provided for people with learning, neurological and physical disabilities. At the time of the inspection there were 27 people living at the service, including one person receiving respite care. One person was in hospital.

The service did not have a registered manager, but had an acting manager who was in the process of applying to register. 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.

People told us they felt safe living at the service and that staff knew how to act to keep them safe from harm. Safeguarding alerts were raised with external agencies however there was limited review and learning by the service after incidents had occurred. The provider reviewed long term trends and supported services to improve. The building and equipment were not always well maintained. We found that some repairs were required and areas needed improved cleaning to control the risk of infection. Staff worked with people to improve their environment and self care skills.

We observed that people had to wait for staff to respond to their needs at times. People told us staffing levels, staff absence and use of agency staff were an issue. Staff were not always properly trained and supported to meet people’s behaviour support needs. We observed that some staff lacked the skills to support people’s behaviour. Not all staff had received appropriate checks by an appropriately skilled person to provide PEG feeding assistance.

Medicines were managed well by the staff and people received the help they needed to take them safely. Where people’s needs changed the staff sought medical advice and encouraged people to maintain their well-being. External healthcare professionals’ advice was sought quickly and acted upon. There were regular meetings with external healthcare professionals.

People were supported by staff who did not always know how best to support them. Staff were generally aware of people’s choices and how they preferred to be cared for, but some care plans lacked personal details. Where decisions had to be made about people’s care, families and external professionals were involved and consulted as part of the process. The service did not always respond quickly to people’s needs as they changed over time. Some reviews of care plans we saw lacked detail about how best to support the individual as their needs changed. The service looked to ensure that records were kept to demonstrate that reviews were occurring. The service supported people to access appropriate external healthcare support so the staff could keep them safe and well.

People were not always supported to maintain a suitable diet. Not all staff were aware of people’s dietary requirements and people told us the choices of food were sometimes limited. People told us there was times when portions were limited. Feedback from the service showed that people could have additional portions or access a skills kitchen themselves. However, not all people seemed to be aware of this or staff did not suggest this to them.

Staff were caring and valued the people they worked with. Some staff showed kindness and empathy in responding to people’s needs. However others did not interact well with people and we observed some negative interactions between staff and people.

Privacy and dignity were not always respected by the staff team. Care notes were not always stored in a confidential manner.

The service did not respond consistently to complaints. Some records did not show how complaints were investigated or resolved or what actions the service had taken. There was limited evidence of learning from complaints within the service.

The acting manager has a process for reviewing the safety of the service. However, there was limited evidence that actions were taken or learning and feedback from previous satisfaction surveys.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

Below is a summary of what we found.

Is the service safe?

Relatives we spoke with told us they were confident that their family members were safe at the home. We found safeguarding procedures were robust and staff understood how to safeguard the people they supported. One relative told us, 'I've never had any worries. I'm happy he is safe, well looked after and cared for.' Another relative said, 'I'm confident that he's safe and sound with them.'

People were cared for in an environment that was safe, clean and hygienic. Equipment at the home had been well maintained and serviced regularly, therefore not putting people at unnecessary risk. There were enough staff on duty to meet the needs of the people living at the home and a member of the management team was available on call in case of emergencies. The building was clean, well maintained and secure and other appropriate measures were in place to ensure the security of the premises. One relative told us, "I am very happy with her care. She's happy there and I'm more than confident that she is safe.' Another relative said, 'I have never found an issue with staff shortages. There are always plenty of staff on duty, he is never left on his own and I find the staff supportive.'

Is the service effective?

People told us that they were happy with the care that was delivered and their needs were met. It was clear from our observations and from speaking with staff that they had a good understanding of the people's care and support needs and that they knew them well. We looked at how staff were supported to deliver care and treatment safely and to an appropriate standard. One relative told us, 'From what I've seen, they definitely seem well trained. They are very good with him and they do a grand job.' Another relative commented, 'The staff are really good, they deal with people very well. I visit regularly and find them polite and more than helpful.'

However, we found that staff did not always receive appropriate training and suitable appraisal and supervision arrangements were not fully in place. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to staff training, appraisal and supervision arrangements.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. Our observations confirmed this. One relative told us, 'The staff are very caring and all his needs are met and he is well looked after.' Other relative's comments, 'The staff are genuinely caring people,' and, 'The staff interact very well with him; his care is good and I have no concerns'

Is the service responsive?

People's needs had been assessed before they moved into the home. Care records for people at the service were reviewed regularly to make sure that the information was accurate and up to date. Where people's needs had changed, their care plans were updated more frequently. Records confirmed people's preferences, interests, aspirations and diverse needs had been recorded and care and support was provided in accordance with people's wishes.

We saw the provider had a written complaints policy and procedure, which detailed the process that should be followed in the event of a complaint. The registered manager told us, and records confirmed that 13 complaints had been received by the service within the 12 months. We also noted that four compliments had been received by the service within the last 12 months.

We saw the service had policies and procedures in place in relation to the safeguarding of adults and Deprivation of Liberty Safeguards. We noted the registered manager had recently made Deprivation of Liberty safeguards applications to the local authority. This meant that people were safeguarded as required and the provider responded appropriately to any potential allegations of abuse.

Is the service well-led?

The service had a registered manager in post, but she was unavailable at the time of the inspection and the service was being managed by an acting manager.

Staff had a good understanding of the ethos of the home and some quality assurance processes were in place. Relatives were able to complete a customer satisfaction survey. Staff told us they were clear about their roles and responsibilities. The provider undertook some audits and risk assessments to monitor the quality of the service and to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

We found that the provider's quality systems were not always effective, or currently undertaken on a regular basis. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to establishing effective systems to assure the quality of the service.

The staff, people who used the service and their relatives said communication was good. One relative told us, 'I find the management more than good and any concerns I have had have been dealt with. X (acting manager) has always told me if I need anything, just to let her know.' Another relative commented, 'X (acting manager) is great, nothing is ever a problem.'

People's needs were assessed effectively. We saw people experienced care, treatment and support that met their needs.

Procedures were in place to manage medicines correctly. There were enough qualified and experienced staff to provide care.

The provider had an effective complaints system in place. Complaints were taken seriously and responded to appropriately.

People who used the service were positive about the care and support provided. Comments included 'The care received is very good' and 'The carers are very caring.'

We saw that people were cared for effectively and that care was planned for the individual. We saw that the home had effective systems in place to monitor its performance and manage emergency procedures. We saw that people were safe.

However we found that there was not always sufficient suitably qualified and experienced staff on duty.

The people staying in the service and the visitors we met during the visit were very positive about the way that the home was managed. Comments included: 'I like it here' and 'I like helping to do the house work with staff'.