CQC report explained · a residential care home
What the CQC found at St Cecilia
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2021
Rated Good; inspectors found safer, personalised care and strong management after the home improved from Requires Improvement.
This was an unannounced focused inspection on 30 June 2021. One inspector spoke with five people living there, four relatives, eight staff members and five health and social care professionals. They also checked care records, medicines records, staff files and management records.
The home was rated Good overall. Safe, Effective, Responsive and Well-led were all rated Good. Inspectors found enough trained staff, safer risk assessments, safe medicines management, good infection control and care plans that were personalised and kept up to date.
The home had improved since its previous inspection, which was rated Requires Improvement and found several breaches of regulations. At this inspection, the provider was no longer in breach of those regulations.
The Caring question was not inspected during this visit because CQC had no concerns about it. Its previous rating was used when calculating the overall rating.
Improved risk management
Risk assessments covered people's care and support needs and were reviewed when circumstances changed. Staff had clear guidance on reducing risks.
“People had risk assessments for all of their care and support needs. Risk assessments were reviewed regularly, and changes made as needed.” from the report
Safe medicines and infection control
Medicines were ordered, stored and recorded safely. Inspectors were also assured that the home was following infection control and COVID-19 guidance.
“Medicines were managed safely. The home had arrangements for ordering, storage and disposal.” from the report
Personalised care
Care plans included people's preferences, personal histories and family information. Staff could see updates quickly through the electronic care planning system.
“Care plans were person centred and detailed, demonstrating staff knew people well.” from the report
Good links with healthcare professionals
The home sought healthcare advice when needed and recorded medical instructions in care plans and handovers.
“Health and social care professionals were overwhelmingly positive about how care was sought for people in a timely manner” from the report
Support to stay connected
The home supported people to keep in contact with relatives during the pandemic through telephone calls, video calls, window visits and face-to-face visits as restrictions eased.
“People had been supported by staff to maintain contact with their relative's and loved ones during the COVID-19 pandemic” from the report
Inspectors raised no specific concerns in this report.
- 01How often are each person's risk assessments and care plans reviewed, and how are changes shared with all staff?
- 02What improvements to the building and decoration are still planned, and how are these monitored?
- 03How will you make sure people continue to have individual and group activities, particularly if COVID-19 restrictions change?
- 04How do you check that weekly audits lead to action and that completed actions remain effective?
- 05How can I see how the home assesses the quality of its caring approach, given that Caring was not inspected at this visit?
This was a focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected and its previous rating was carried forward. This explanation was written from the published report of 22 July 2021 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, November 2019
St Cecilia: Rated Requires Improvement; inspectors found kind care but gaps in care planning, risk checks and oversight.
The inspection was unannounced and took place on 9 and 14 October 2019. One inspector spoke with a person living in the home, relatives, staff and visiting health professionals. They also checked care files, medicines records, staff records and management records.
The home provided care for up to 15 older people living with dementia. Staff were kind and attentive. Families and professionals spoke positively about the care, meals, activities and management. Staffing, recruitment, training and medicines administration were generally good.
However, important checks were not always completed or kept up to date. Some people did not have full risk assessments or care plans. There were also problems with parts of the building, infection control, records, audits and required notifications. The home breached three regulations and was rated Requires Improvement overall.
Kind and respectful care
Families and visiting professionals consistently praised the care. Inspectors saw staff giving people time, comfort and explanations, while respecting privacy and dignity.
“We observed staff giving time to people, providing support at the persons pace, offering comfort when people were upset or anxious.” from the report
Enough suitable staff
There were enough staff to meet people's assessed needs. Recruitment had improved since the previous inspection, with references and criminal record checks completed.
“People were supported by enough staff to meet their assessed needs.” from the report
Training and health support
Staff had induction, ongoing training and regular checks of their skills in medicines and moving people safely. The home worked well with health professionals.
“Staff had completed an induction and had on-going training and support that enabled them to carry out their roles effectively.” from the report
Food and activities
People were offered home-cooked meals, drinks and a range of activities. The kitchen had a five-star food hygiene rating from the local authority.
“Home cooked, well balanced meals were served to people and a range of drinks offered throughout our inspection.” from the report
Incomplete risk assessments
seriousTwo people had no recorded assessments of risks such as skin damage, mobility, nutrition and dementia-related needs since admission. Emergency evacuation plans and risks linked to the open staircase were also not always addressed.
“Risks to people had not been assessed, monitored and reviewed to minimise the risks of avoidable harm.” from the report
Care plans were missing
seriousCare plans were not in place for everyone and did not always reflect people's needs, choices or dementia-related behaviours. This could lead to inconsistent or unsuitable care.
“Care had not been planned based on a person's assessment of care needs or preferences that were personal to them.” from the report
Problems with the premises
needs fixingInspectors found an unsecured wardrobe, a frayed carpet, and a damaged chair and mattress with exposed foam. These issues could affect safety and infection control.
“A dining chair and mattress were in poor repair with the foam filling exposed which meant cleaning was compromised in preventing infections.” from the report
Weak records and oversight
seriousAudits had not identified the problems found. Care records were incomplete and some serious incidents and a deprivation of liberty safeguard had not been notified to the regulator as required.
“Auditing systems had failed to highlight shortfalls found at this inspection and did not ensure risks to people had been effectively managed.” from the report
Medicine storage
needs fixingMedicines needing refrigeration were kept in an unlocked domestic fridge with food and drinks. The manager said this arrangement would be reviewed and a lockable medicines fridge organised.
“These medicines were stored in an unlocked domestic fridge along with food and drinks.” from the report
- 01Which people now have complete risk assessments for mobility, nutrition, skin damage, dementia and use of the stairs?
- 02How do you make sure every person's care plan reflects their needs, choices and dementia-related behaviours?
- 03Have the damaged furniture, frayed carpet and unsecured wardrobe been repaired or replaced?
- 04How are audits now checking that care records are complete and that required notifications are submitted?
- 05Are medicines needing refrigeration now kept in a lockable medicines fridge, separate from food and drinks?
This was a planned but unannounced inspection covering all five CQC questions, including both the care provided and the premises; the previous rating was Good in 2017. This explanation was written from the published report of 15 November 2019 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
3 rated inspections over 4 years: the service has held its Good rating throughout.
- July 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2017GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- October 2012
Registered with the Care Quality Commission on 12 October 2012.
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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