Background to this inspection
Updated
12 June 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection team was made up of one inspector and one specialist advisor. The specialist advisor was a specialist nurse with experience of rehabilitation services.
Service and service type
STEPS Neurological and Trauma Rehabilitation Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The clinical director was managing the service and in the process of registering as the manager with CQC. The clinical director was also the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
Notice of inspection
This inspection was announced.
What we did before the inspection
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority, clinical commissioning group and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used this information to plan our inspection
During the inspection
We spoke with four people who were staying at STEPS Neurological and Trauma Rehabilitation Centre about their experience of the care provided. We met with the nominated individual and head of nursing. We spoke with eight members of staff.
We looked around the building to check environmental safety and cleanliness. We looked at written records, which included five people’s care records and four staff files. A variety of records relating to the management of the service were also reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. This included reviewing feedback about the service and quality assurance records.
Updated
12 June 2021
About the service
STEPS Neurological and Trauma Rehabilitation Centre is a purpose-built care home providing specialist rehabilitation services to people living with neurological conditions, stroke, spinal cord injuries, acquired brain injuries, orthopaedic and other complex trauma injuries. The duration of stay is dependent upon each person's rehabilitation programme. At the time of the inspection there were 21 people living at the home. The service can support up to 23 people.
People’s experience of using this service and what we found
People told us they felt safe living at STEPS Neurological and Trauma Rehabilitation Centre. There were systems in place to recognise and respond to any allegations of abuse. Staff had received training in safeguarding adults and children. Medicines were stored safely and administered as prescribed. Safe recruitment procedures made sure staff were of suitable character and background. There were enough staff deployed to meet people’s care and support needs in a timely way. We were assured there were effective systems in place to reduce the risk of infections.
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 supported this practice.
The service was well-led. There were multiple systems in place to regularly ask people, their relatives, staff and stakeholders for their views on the service. Actions were taken in response to feedback received. Comments about the managers were positive. The service had up to date policies and procedures which reflected current legislation and good practice guidance. There were effective systems in place to monitor and improve the quality of the service provided.
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 ‘inspected but not rated’ (published 11 November 2020). This was a targeted inspection and we found two breaches of regulation 12. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
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.
We carried out an unannounced targeted inspection of this service on 29 September 2020. Two breaches were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve their provision of safe care and treatment.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions of safe and well-led which contain those requirements.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion (effective, caring and responsive) were used in calculating the overall rating at this inspection. The overall rating for the service has remained good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for on our website at www.cqc.org.uk
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.