St Stephens Nursing Home

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 changed to Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 57 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Although leaders had a vision for the service, this had not yet been fully realised and the model of care during our inspection did not comply with RSRCRC guidance. The manager explained to us their focus was increasing the level of activity provision to ensure this promoted people’s right to meaningful engagement. However, it was not clear how people had been engaged in their own care to ensure each person’s experience of St Stephen’s reflected their own wishes and aspirations. Some elements of care were restricting people’s choice or ability to involved in their own care and people did not have equity of experience or access. There had not been a service user meeting for 5 months to ensure people’s voice was consistently used to shape how the service operated.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Leaders at the service had plans to improve people’s experience of care, but did not fully understand current best practice for maximising people’s choice, independence and rights. They had not ensured that governance systems were fully reviewing people’s experience of care and involving them in this process. The registered manager confirmed they had not conducted a night visit since starting in October 2025, which meant they had not checked or observed the care being delivered during a significant proportion of the day. This was despite staff raising concerns about staffing levels and frequent occasions when the home was operating with insufficient staff to meet people’s needs.

However, people, relatives and staff spoke of positive relationships with the registered manager and how they led with compassion and care. They recognised the work they were undertaking to improve the service. One person told us ““(Manager name) is very nice, she listens to you.” A relative added “I can feel she’s putting her stamp on it, making a few small changes, she wants the clients to get out and have more of a normal life”.

The provider fostered a culture where people felt they could speak up and leaders were accessible, however they did not always feel their concerns had been responded to.
Although staff we spoke to felt comfortable in raising concerns and that they would be listened to, we found prompt action had not always been taken in response. When staff had raised concerns about the level of staffing at the service, this had not been responded to appropriately until the time of the inspection. Staff had been working shifts without the support they needed to support people safely. One member of staff told us “Even in the daytime we sometimes work as 3 or 4 staff, and we cannot give people proper care”
 

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.

Staff were trained in equality and diversity, and expressed they were treated with respect and adaptions made if needed for their own personal circumstances. One staff member told us “If I have any personal issues the manager is really happy to help and flexible”. Others told us about difficult situations at work and how they had been handled sensitively by management and improved their experience of working at St Stephens.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems did not consistently identify, reviewed or flagged responsive action to ensure people received a safe or person-centred level of care. Although processes in place to manage clinical risks were largely robust, there was no clear system to review and monitor the outcomes people wanted from their care. This meant people’s experience was not consistently person centred and opportunities had been missed to ensure people were meaningfully engaged in their own care.

There was a regular system of auditsand checks undertaken by both the registered manager and the provider, which were largely focused on clinical risks rather than people’s quality of life and engagement. Care documentation was reviewed regularly to ensure it remained up to date and there was a routine schedule of checks to identify and resolve any problems with the property or equipment. Staff received appraisals and supervisions to monitor their wellbeing and ability to perform their role safely. However, these systems had not ensured staff’s ability to perform high risk tasks safely was appropriately assessed in all cases.

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.

In the majority of cases we could see there were clear systems for working in partnership with health and care partners and referrals were made in a timely way to ensure people received the support when they needed it. One stakeholder told us “The home has always been welcoming towards visiting professionals, and I have been impressed by the friendliness and helpfulness of the staff”. Another person who worked with the home added “Staff have a great knowledge of each person individually, without the need to check records. This impresses me on every visit. The nurses work very professionally any health issues are dealt with appropriately and in a timely manner”.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There were some systems to share learning at the service, however leaders had not ensured all opportunities to learn were actively taken to drive improvement. There was no system to analyse incidents and accidents for trends or themes, or having focused debriefs with the staff involved as standard to fully explore any contributory factors. Staff meetings took place but we did not see clear evidence of how when things went wrong, these were being discussed together with staff to learn as a team. However, some systems in place to support learning had been effective. There were monthly audits to review that medication was administered safely, and had identified a number of areas where practice needed to be improved. During our inspection we found these issues had been remedied and staff were following best practice for administering medication safely.