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