This inspection took place on 05 October 2016 and was unannounced.

St Stephens Nursing home is registered to provide accommodation, personal and nursing care for up to 17 people who need support with their learning disability, physical disability and health needs. The service is situated close to the town centre of Dover where all amenities are close by. There were 14 people at the service at the time of the inspection.

The care and support needs of the people varied greatly. There was a wide age range of people living at the service with diverse needs and abilities. As well as needing support with their learning disabilities, some people had physical disabilities and needed a lot of care interventions and treatment for their health needs. There were registered nurses working 24 hours a day to make sure people’s complex nursing needs were met.

There was a registered manager working at the service. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run.

We carried out an unannounced comprehensive inspection of this service on 20 August 2015, the service was rated ‘Requires Improvement’. We issued requirement notices relating to safe care and treatment, fit and proper persons employed and staffing. We asked the provider to take action and the provider sent us an action plan. The provider wrote to us to say what they would do to meet legal requirements. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. Improvements had been made the provider had complied with the previous breaches of regulations but we found some other areas that needed improvement.

Safeguarding procedures were in place to keep people safe from harm. On three occasions these procedures had not been fully followed. The local authority safeguarding team had not been alerted to incidences, which they should have been, as part of those procedures. People told us they felt safe at the service; and if they had any concerns, they were confident these would be addressed quickly by the registered manager. The staff had been trained to understand their responsibility to recognise and report safeguarding concerns and to use the whistle blowing procedures. Systems were in place to ensure that people's finances were protected.

At the previous inspection risks to people were assessed but guidance had not always been available to make sure all staff knew what action to take to keep people as safe as possible. At this inspection improvements had been made but there were still areas that needed further improvement. Risks to people's safety were assessed and on the whole there was guidance for staff on how to keep risks to a minimum. Risk assessments identified people's specific needs, and showed how risks could be minimised. However, during the inspection we found that a person was potentially at risk as the power supply to a special mattress to protect their skin and reduce the risk of pressure sores developing had been turned off. The registered manager took immediate action to address this issue.

The registered manager and staff carried out other environmental and health and safety checks to ensure that the environment was safe and that equipment was in good working order. Accidents and incidents were recorded and were reviewed to identify if there were any patterns or if lessons could be learned to support people more effectively to ensure their safety.

Emergency plans were in place so if an emergency happened, like a fire, staff knew what to do. There were regular fire drills so people knew how to leave the building safely.

On the whole people received their medicines safely and when they needed them. People'

This inspection took place on 20 August 2015 and was unannounced. It was carried out by two inspectors and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

St Stephens is registered to provide accommodation, personal and nursing care for up to 17 people who need support with their learning disability, physical disability and health needs. The service is situated close to town centre of Dover where all amenities are close by. There were 15 people at the service at the time of the inspection.

The care and support needs of the people varied greatly. There was a wide age range of people living at the service with diverse needs and abilities. The youngest person was in their 30’s and the oldest was in their late 70’s. As well as needing support with their learning disabilities, some people had physical disabilities and needed a lot of care interventions and treatment with their health needs. There were registered nurses working 24 hours a day to make sure people’s complex nursing needs were met.

At the time of the inspection the service did not have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run. The most recent registered manager had left the service in May 2015. The provider had appointed a new manager who had been in post for a month but had worked at the service in a different role for over five years. The manager was in the process of applying to become registered with the CQC.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The people at the service had been assessed as lacking mental capacity to make complex decisions about their care and welfare. At the time of the inspection the manager had applied for DoLs authorisations for people who were at risk of having their liberty restricted. We received information from the service, informing us that two people had applications granted to deprive them of their liberty, to make sure they were kept as safe as possible. The remainder of the applications were still being processed by the DoLS office. The manager was waiting for the outcome of the applications from the local authorities, who paid for the people’s care and support. There were records to show who people’s representatives were, in order to act on their behalf if complex decisions were needed about their care and treatment.

Before people decided to move into the service their support needs were assessed by the manager, to make sure they would be able to offer them the care that they needed. The care and support needs of each person were different and each person’s care plan was personal to them. People or their relative /representative had been involved in writing their care plans. The care plans recorded the information needed, to make sure staff had guidance and information to care and support people in the safest way, and in the way that suited them best. People were satisfied with the care and support they received. Potential risks to people were identified but full guidance on how to safely manage the risks was not always available. This left people at risk of not receiving the interventions they needed to keep them as safe as possible. People had regular reviews of their care and support, when they were able to discuss any concerns or aspirations and goals they wanted to achieve.

People had an allocated keyworker who was involved in their care planning and reviews. A key worker was a member of staff who took a key role in co-ordinating a person’s care and support and promoted continuity of support between staff. The key worker was a member of staff who the person got on well with and were able to build up a good relationship with. Whenever possible people were supported and cared for by their keyworker. People knew who their keyworker was.

The service was planned around people’s individual preferences and care needs. They told us they received care that was individual to them. They felt staff understood their specific needs. Staff had built up relationships with people and were familiar with their life stories, wishes and preferences. This continuity of support had resulted in the building of people’s confidence to enable them to make more choices and decisions themselves and become more independent.

Throughout the inspection we observed people and the staff as they engaged in activities and relaxed at the service. Some people could not communicate verbally. Staff understood the needs of the people they supported. Staff were able to understand people through body language, facial expressions and certain sounds and supported people in a discreet, friendly and reassuring manner. Staff asked people if they were happy to do something before they took any action. They explained to people what they were going to do and waited for them to respond. Throughout the inspection people were treated with kindness and respect. People told us their privacy was respected and they were able to make choices about their day to day lives. People’s bedrooms were personalised and furnished with their own things. The rooms reflected people’s personalities and individual tastes.

People were offered and received a balanced and healthy diet. Some people were not able to eat without support and had a special way of receiving all the nutrients and fluids they needed. When people were able to eat independently, they were able to choose what they wanted to eat and when they wanted to eat it. If people were not eating enough, they were seen by dieticians or their doctor and supplement nutrition was provided. People received their medicines safely and when they needed them and they were monitored for any side effects. If people were unwell or their health was deteriorating the staff contacted their doctors or specialist services.

People had their needs met by sufficient numbers of staff. Staff numbers were based on people’s needs, activities and health appointments. People received care and support from a dedicated team of staff that put people first and were able to spend time with people in a meaningful way.

Staff had support from the manager to make sure they could care safely and effectively for people. Staff said they could go to the manager at any time and they would be listened to. The manager was actively involved with people on a day to day basis. Staff had received regular one to one meetings with a senior member of staff. Staff had not received an annual appraisal for 2014 so had not had the opportunity to discuss their developmental needs for the following year.

Staff had completed induction training when they first started to work at the service, and had gone on to complete other basic training provided by the company. There was also training for staff in areas that were specific to the needs of people, like epilepsy, learning disabilities and dementia. Some of the staff had not received this training, so there was a risk that they may not know what to do in certain situations. Some people at the service had very specialist needs like autism but there was no training for staff in this area. There were staff meetings so staff could discuss any issues and share new ideas with their colleagues to improve people’s care and lives.

A system to recruit new staff was in place. This was to make sure that the staff employed to support people were fit to do so. However, all the checks that needed to be carried out on staff to make sure they were suitable and safe to work with people had not been completed by the manager.

People were protected from the risk of abuse. Staff had received safeguarding training. They were aware of how to recognise and report safeguarding concerns both within the company and to outside agencies like the local council safeguarding team. Staff knew about the whistle blowing policy and were confident they could raise any concerns with the manager, provider or outside agencies if needed. The manager responded appropriately when concerns were raised.

Emergency plans were in place so if an emergency happened, like a fire the staff knew what to do. Safety checks were done regularly throughout the building and there were regular fire drills so people knew how to leave the building safely.

People felt comfortable in complaining and when they did complain they were taken seriously and their complaints were looked into and action was taken to resolve them.

There were quality assurance systems in place. Audits and health and safety checks were regularly carried out. The manager had sought formal feedback from people by using a questionnaire. The questionnaire used was not written in a format that would make it understandable and meaningful for people. Relatives and other stakeholders had been asked their opinion about the service. Their opinions had been captured, and analysed to promote and drive improvements within the service. Informal feedback from people, their relatives and healthcare professionals was encouraged and acted on wherever possible. Staff and people told us that the service was well led and that the manager was supportive and approachable and sometimes worked alongside the staff. There was a culture of openness and transparency within St. Stephens which allowed everyone to suggest new ideas which were acted on and to discuss any concerns.

The manager had a vision, to be a leading service, providing quality care and support for adults with learning disabilities and physical health needs. Their aim was to provide a safe and fulfilling life for people. Staff were very aware of these and they were followed through into practice.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

There were 15 people using the service at the time of the inspection. We found that people were asked to give consent and were involved in the decisions about the care and support they received. People told us and indicated that they were asked for consent before any care took place and their wishes were respected.

People who used the service told us and indicated that they were happy at the home. They were relaxed and responsive in the company of staff. They were able to let staff know what they wanted and we saw staff respond in a caring and positive way. People said that there were enough activities and that they enjoyed going out in the local area and doing different things.

People's health needs were supported and the service worked closely with health and social care professionals to maintain and improve people's health and wellbeing.

People told us and records confirmed that medicines were given to people when they needed them in a safe way.

Staff were received the training they needed to do their jobs safely and effectively. All the staff we spoke with said that they felt supported and that this was the best place they had worked. One member of staff said, “It’s like a family here”.

People and their relatives told us they did not have any complaints about the service. They were confident if they did the manager would take action to resolve any issues.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not all able to tell us their experiences.

During our visit we spoke with three people who used the service and five members of staff including the manager and the head nurse. We also observed people being supported by staff in the service.

People told us they were happy with the care they received and they felt that they were listened to and well looked after. People said that their care needs had been discussed with them when they moved into the service.

We saw that people were treated with dignity and respect and had choice, and their views and needs were taken into account. We found that safeguarding issues were understood and addressed.

People who used the service told us that they do lots of activities and enjoy a lot of choice. Staff felt supported and understood the needs of the people including those who were unable to communicate verbally.

The service had systems in place to monitor the quality of support delivered.

We found that some staff had gaps in their training record. We found that there were a lack of supervisions of the manager and staff. Although staff told us they felt supported and said that there had been improvements in this area, at the time of our inspection there were staff who had not completed training in key areas.

Some of the people who use services had special communication needs and used expressions, single words and gestures to express themselves.

People who use services said or showed us that the staff treated them with respect, listened to them and supported them to raise any concerns they had. They said or showed us that they received the health and personal care they needed and that they were comfortable in their home. One person said, 'I like all the staff here because they're good and friendly to me and help me with things like going out'.