About the service: Stepping Stones is a residential care home that provides accommodation and personal care for up to 15 people with a physical disability. Some people may also have some learning difficulties. These needs may or may not be associated with their physical disability. The care home is located on one site, but split across two bungalows and three individual flats. On the day of the inspection 14 people were living at the service.

People’s experience of using this service:

• People who had lived in the service for many years mainly said they were happy. People commented about aspects of the environment, and said they wished some things could be better. People spoke in a way that suggested they had accepted aspects of their care and did not know to question anything different. For example, one person had no lampshade and just a light bulb in the centre of their room. They said it had been like it for a long time, but they said they would like to have a lampshade. People did say there had been improvements since the new registered manager had started working in the home.

• Risks in relation to people’s care and lifestyle were not assessed, understood and managed in a way that kept them safe. Some practices in relation to risk did not protect people’s human rights.

• People did not live in an environment that was well-maintained or promoted their dignity and independence.

• People’s rights in relation to their capacity had not been fully understood and respected. Correct processes had not always been followed when people lacked ability to make decisions about their care.

• Risks and needs in relation to people’s physical and mental health had not in all cases been consistently understood and supported.

• The culture of the service did not always respect and promote people’s rights, dignity and independence.

• The leadership and auditing of the service had not been robust and had failed to identify the concerns we found in relation to practice, the environment and culture of the service. This meant that people had continued to receive a service that was not fully safe, effective, caring or responsive to their needs.

• The provider had failed to act on some areas of concerns found at the last inspection. Although some improvements had started and were planned, it was not possible to see the impact this would have on people or if these improvements would be sustained.

• The service is now judged to be inadequate in keeping people safe, providing effective care and being inadequately well-led.

Rating at last inspection: The rating at the last inspection was Requires improvement overall. (The report was published on the 27 April 2018)

Why we inspected: We inspected in line with our inspection methodology. This was within 12 months of publication as the service had been judged to be requires improvement in safe, effective, caring, responsive and well-led at the last inspection.

Enforcement

At our last inspection we told the provider to provide us with an action plan about how they would ensure compliance with the regulations and by when. At this inspection we found action had not been taken to address all the concerns and breaches of regulations found at the previous inspection.

We have made a recommendation about the management of medicines, accessible information, fire safety, and end of life care.

In respect of this inspection, full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Follow up:

Following the inspection we spoke to Plymouth City Council about our initial findings and practices we had concerns about.

The overall rating for this registered provider is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly

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 und

The inspection took place on the 9th and 10th December 2015 and was unannounced.

Stepping Stones is a residential care home providing care and accommodation for up to 15 people. On the day of the inspection 15 people were using the service. Stepping Stones provides care for people with a learning disability and people with physical disabilities.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission 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 2008 and associated Regulations about how the service is run.

During the inspection people and staff were relaxed; the environment was clean and clutter free. There was a happy, calm and pleasant atmosphere. People confirmed staff were kind to them and told us “Very caring, they ask me what I want to do”; “They are kind and caring, no problems with the staff, they are gentle and make me laugh, they spend time talking to me, play games with me.”

Care records were focused on giving people control and encouraging people to maintain their independence. People and those who mattered to them were involved in identifying people’s needs and how they would like to be supported. People preferences were sought and respected. People’s life histories, disabilities and abilities were taken into account, communicated and recorded, so staff provided consistent personalised care, treatment and support.

People’s risks were known, monitored and managed well. There was an open, transparent culture and good communication within the staff team. Accidents and incidents were recorded and managed promptly. Staff knew how to respond in a fire and emergency situation. There were effective quality assurance systems in place. Incidents related to people’s behaviour were appropriately recorded and analysed to understand possible triggers and reduce the likelihood of a reoccurrence.

People were encouraged to live active lives and were supported to participate in community life where possible. Activities were meaningful and reflected people’s interests and individual hobbies for example football, theatre trips and shopping outings. People also enjoyed activities within the home such as arts and crafts and board games.

People had their medicines managed safely. People received their medicines as prescribed, received them on time and understood what they were for where possible. People were supported to maintain good health through regular visits with healthcare professionals, such as GPs and dentists and the specialists involved in their specific health care needs.

People and staff were encouraged to be involved in regular meetings held at the home to help drive continuous improvement. Listening to feedback helped ensure positive progress was made in the delivery of care and support provided by the home.

People knew how to raise concerns and make complaints. People and those who mattered to them explained there was an open door policy and staff always listened and were approachable. People told us they did not have any current concerns but any previous, minor feedback given to staff or the registered manager had been dealt with promptly and satisfactorily. Any complaints made would be thoroughly investigated and recorded in line with Stepping Stones own policy.

People told us they felt safe and secure. People’s personal possessions and their money was kept safely. Comments included, “Yeah, they help you; they make sure I’m safe – check my wheelchair is working, I’m wearing my belt”; “I have my own bank account, my card is kept safely in the office and I can have it whenever I want.”

Staff understood their role with regards the ensuring people’s human rights and legal rights were respected. For example, the Mental Capacity Act (2005) (MCA) and the associated Deprivation of Liberty Safeguards (DoLS) were understood by staff. All staff had undertaken training on safeguarding adults from abuse; they displayed good knowledge on how to report any concerns and described what action they would take to protect people against harm. Staff told us they felt confident any incidents or allegations would be fully investigated.

Staff received a comprehensive induction programme specific to Stepping Stones and the Care Certificate (a new staff induction programme) had been implemented within the home. There were sufficient staff to meet people’s needs. Staff were very kind, caring and thoughtful. Staff ensured people mattered and cared for people’s families and relatives. Staff were appropriately trained and had the correct skills to carry out their roles effectively.

Staff described the management as open, very supportive and approachable. Staff felt like part of a large family and talked positively about their jobs. Comments included “X is always positive, well organised, our ideas are listened to; and “There is always someone to go to.”