CQC report explained · a residential care home
What the CQC found at St Cecilia Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found that risks were not always fully assessed, monitored or managed. They also found weaknesses in falls monitoring, care planning, legionella checks and the assessment of staffing levels.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- The provider did not have effective formal audits or records of its oversight visits. The systems were not strong enough to identify and address risks and other shortfalls.
What inspectors found, March 2023
Rated Requires Improvement; inspectors found risks were not always managed and quality checks were not strong enough.
Inspectors visited on 11 and 12 January 2023. The first day was unannounced and the second was announced. They spoke with people, relatives and staff, observed care, checked records and medicines, and contacted health professionals.
The home was rated Requires Improvement for Safe and Well-led. Inspectors found that some risks were not properly assessed or monitored. Care plans were missing for one person after a serious injury, falls were not analysed for lessons, and checks for legionella were not regular enough.
There were also positive findings. Medicines and infection control were managed safely, recruitment checks were in place, and people and relatives said they felt safe and were happy with the care. The provider acted during and after the inspection and was required to report what it would do to improve.
Medicines
Medicines were managed safely. Staff who administered them had training and their competence was checked.
“Medicines were managed safely. Staff who administered medicines received training in safe medicine administration and the provider checked they were competent to do so.” from the report
Infection control
Inspectors were assured about infection prevention, the use of protective equipment and the home's ability to manage infection outbreaks. The home appeared clean and well maintained.
“The service appeared clean and was well maintained.” from the report
People felt safe
People and relatives gave positive feedback about safety and the care received.
“People and relatives told us people felt safe with the care and support they or their relative received.” from the report
Recruitment
Recruitment procedures included checks to help ensure staff were suitable to work with vulnerable adults.
“Recruitment procedures ensured people were supported by staff with the appropriate experience and character.” from the report
Staff support
Staff said they felt supported by colleagues and management, and inspectors described a friendly atmosphere.
“Staff were happy in their jobs which created a friendly atmosphere for people.” from the report
Partnership working
The home worked with health and social care professionals, who gave positive feedback about the service.
“The service worked in partnership with external agencies such as GP's, local authorities and other health and care professionals.” from the report
Risk assessments and care plans
seriousRisks were not always assessed, monitored or managed properly. One person did not have a care plan or risk assessment after returning from hospital following an injury.
“The provider did not always follow their system to assess risks to people before undertaking their care and support.” from the report
Falls and water safety
seriousThe home did not look for patterns in accidents and falls or use them to reduce future risk. Legionella risks were also not managed with regular checks of water points and tanks.
“Records of incidents, accidents and falls were recorded, although there was no system in place to look for trends, identify any learning, and reduce the risk of an incident happening again.” from the report
Staffing levels
needs fixingThe home did not have a reliable method for checking whether enough staff were available at the right times to keep people safe. Inspectors made a recommendation about this.
“The provider did not have an effective system, such as a staff dependency tool to assess staffing levels were sufficient at the right times to keep people safe.” from the report
Quality monitoring
seriousFormal audits and records of provider visits were not strong enough to identify shortfalls or check that improvements were completed.
“The service did not have a robust system in place to monitor the quality and safety of the service.” from the report
- 01What system do you now use to assess whether staffing levels are sufficient at different times of day?
- 02How are falls and other incidents now reviewed for patterns and lessons?
- 03How do you make sure every person has an up-to-date care plan and risk assessment, especially after an injury or hospital stay?
- 04How often are sentinel points and hot water tanks checked for legionella risks, and where are those checks recorded?
- 05What formal audits and provider visit records are now in place to identify shortfalls and track improvements?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection in 2018. This explanation was written from the published report of 15 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2018
Rated Good; inspectors found safe, kind and flexible care, but communication and end-of-life planning needed improvement.
The inspection took place on 22 and 27 February 2018. It was unannounced on the first day and announced on the second. One inspector spoke with people living in the home, relatives, staff and health professionals, and reviewed care records, medicines, staffing, training, incidents and audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people felt safe, staff were available, medicines were managed safely and staff had training to support people living with dementia.
Inspectors found warm and respectful relationships. People had choices about their routines, meals and activities, and relatives were welcomed. However, some people living with dementia did not have suitable ways to express their views, and care plans did not record some end-of-life wishes.
People felt safe
People and relatives said they felt safe and cared for. Inspectors found safe medicines systems, suitable recruitment checks and staffing arrangements that supported people's needs.
“People told us they felt safe living in the home and described staff as "Kind" and "They are all lovely.” from the report
Dementia-focused training
Staff received training designed to help them understand what it felt like to live with dementia and depend on staff for comfort and support.
“This meant staff received innovative training to enable people to receive support and assistance from staff who had greater understanding and empathy of people's experience of living with dementia.” from the report
Kind and respectful care
Staff were patient, compassionate and respectful. People were supported to make choices, keep their routines and maintain their privacy and independence.
“Staff interacted with people in a warm and caring way.” from the report
Activities and community links
People could take part in varied activities and use local facilities. The home also worked with community groups, including a local singing group.
“This enabled people to maintain their hobbies/lifestyle following admission to the home.” from the report
Limited ways to express views
needs fixingThere were no suitable questionnaires or other specific tools for some people living with dementia and communication difficulties to express their views. This could make it harder for the home to understand their feedback.
“There was none which could be used where people living with dementia and who may have communication difficulties, verbal and non-verbal, could be enabled to express their views.” from the report
End-of-life wishes not recorded
needs fixingCare plans did not include some people's wishes about end-of-life care or where they wanted to receive it. The manager said this would be addressed.
“However, there was no specific information about decisions and wishes some people may have made about their end of life care or where they wished to receive the care.” from the report
- 01What tools do you now use to help people with dementia and communication difficulties express their views?
- 02How do you discuss and record each person's wishes about end-of-life care?
- 03How often are end-of-life wishes reviewed with the person and their family?
- 04How do you make sure staffing remains sufficient when people need extra support or become disorientated?
- 05What activities and opportunities are currently available for residents to use local community facilities?
This inspection looked at the overall quality of the care home and rated all five CQC areas: Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 21 June 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of St Cecilia Care Home
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2018GoodSafe: GoodWell-led: Good
- February 2017
Registered with the Care Quality Commission on 6 February 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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