Updated 19 February 2026
Date of Inspection: 14 April 2026 to 23 April 2026. St Stephens Nursing Home is a care home providing nursing and residential care to up to 17 adults with a learning disability and autistic people. At the time of our inspection 17 people were living at the service.
The service was previously rated “Good”. Following our inspection this has changed to “Requires Improvement”.
We assessed the service against ‘Right support, right care, right culture’ (RSRCRC) guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We found the service was not consistently reflecting this guidance, and there were no clear processes to involve people in their own care to maximise their independence and control over day to day life.
The new manager had a vision to increase the provision of activities at the service, but as yet this has not been achieved. People spent the majority of time watching television in a communal lounge and on most days there was either no scheduled activity or those that were scheduled were accessible only to a minority of people at a time. Some people were restricted as to when they left the service because there were not sufficient staff trained in their specific needs to allow them to do so.
Although we saw and heard some caring interactions with staff, people also went long periods of time without any meaningful engagement. Some people had been exposed to potentially distressing situations without adequate thought given to how they might have been prevented. This did not ensure people received the stimulation the required to support consistent mental wellbeing and maximised quality of life. It was not clear what people wished to achieve from living at St Stephen’s and people were not being supported to achieve aspirations or goals.
Staffing levels at the service were not consistently safe and meant people were exposed to a higher risk of harm or delayed care particularly at night. The systems in place to assess staff competency for performing complex tasks were also ineffective. However, staff spoken to did have a good level of knowledge about the people they supported. They were also trained in safeguarding and knew what actions to take to protect people from the risk of abuse or neglect.
There were detailed assessments of people’s needs which set out clear guidance of how staff would support people safely. These were regularly reviewed to ensure they remained up to date and were generally monitored well to make sure people could access the support they need if their health were to deteriorate.
Governance systems were largely effective at monitoring clinical risks, however, leaders were not robustly reviewing people’s experience of care and how their quality of life could be maximised.
People lived in a space that was clean and was personalised to reflect people’s interests and personalities. It was however a noisy environment and was not always adapted to the needs of people to encourage their independence.
We heard examples of the service making a significant and positive difference to people’s quality of life, however further steps were needed to ensure this was consistently the case for everyone and that people were fully involved in their own care.
The service worked in partnership with wider health and social care organisations, including making timely referrals. People, relatives and partners spoke of positive relationships with leaders and that they communicated openly and acted with integrity. However, they had not always understood current best practice care for people with a learning disability and autistic people, or ensure this was embedded in practice.
We identified 5 breaches in regulation relating to person centred care, dignity and respect, safe care and treatment, good governance and safe staffing. We have requested an action plan from the provider to set out how they will address the concerns identified during the inspection.