This inspection took place on 30 May 2018 and was unannounced. This meant the staff and registered provider did not know we would be visiting.

STEPS Neurological and Trauma Rehabilitation Centre is a registered 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 inspected during this inspection. The service is a specialist neurological and complex trauma rehabilitation for traumatic and acquired brain injury including stroke, amputee rehabilitation, complex orthopaedic injuries and other neurological conditions including Parkinson’s disease and Multiple Sclerosis. STEPS also provide post-operative convalescence and active respite for people living with long-term conditions. The service has specialist facilities such as a hydrotherapy pool. The service can provide accommodation for up to 23 people. At the time of the inspection, eight people were using the service.

The manager had registered with the Care Quality Commission. 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, we found some concerns about the care planning software being used at the service as relevant care planning documentation was not located within the system. The nominated individual told us improvements to the software had been identified by senior management and the developer was being asked to make these improvements as a matter of urgency.

Staff underwent an induction and shadowing period prior to commencing work. We saw that care staff had undertaken an introduction to the Rehabilitation Competency Framework. However, staff training records showed some staff had not completed relevant training so they had the appropriate skills.

Systems were in place for the registered provider to respond to safeguarding concerns, accidents and incidents so correct procedures were followed to maintain people’s safety and learn from these where things had gone wrong. Relatives we spoke with did not have any worries or concerns about their family member’s safety and felt they were in a safe place.

Individual risk assessments were completed for people so that identifiable risks were managed effectively.

We saw there were sufficient staff with the right mix of skills to provide support to people who used the service.

There were recruitment procedures in place to help keep people safe.

The service had appropriate arrangements in place to manage medicines so people were protected from the risks associated with medicines.

The service was clean. Throughout the inspection, there was a buoyant and caring atmosphere at the service.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

We saw assisted technology was used effectively to assist people to be involved in their care planning and pursue their independence.

Relatives we spoke with made positive comments about the care their family member had received and about the staff who worked at the service.

We saw that a range of therapy was provided to people who used the service. For example, physiotherapy, neuropsychology, psychological art therapies, hydrotherapy, acupuncture, occupational therapy and psychological therapies. This support empowered people to facilitate recovery and overcome barriers to do activities that matter to them.

People were supported with their health and dietary needs, where this was part of their plan of care. We received positive comments about the quality of food provi