St Bridgets Care Centre

Updated 9 September 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

St Bridgets Care Centre is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. St Bridgets Care Centre is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service. We sought feedback from the local authority service improvement and safeguarding teams who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with five people who used the service and four relatives about their experience of the care provided. We spoke with nine members of staff including the registered manager, chef, care workers and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We received feedback from two health and social care professionals who work with the home. We made general observations throughout the two days, noting care practices and interactions between staff and people.

We reviewed a range of records. This included six people's care records and six medication records. We looked at six staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data, policies and procedures.

Updated 9 September 2022

About the service

St Bridgets Care Centre is a residential care home registered to provide personal care and support for up to 12 people. The service provides support to older people. There were eight people using the service at the time of inspection.

People’s experience of using this service and what we found

Improvements were needed to the governance systems within the service. The systems for monitoring and checking the home operates in a safe way were not effective. The service did not actively seek feedback from others in order to drive improvements within the service. Policies and procedures were either not in place or up to date to support the systems and processes within the service. The provider did not carry out any formal checks of the service.

People had risk assessments in place for their care and support needs. However, assessments were not always detailed and the use of different formats meant it could be confusing for staff. The registered manager told us they were working to ensure assessments were clear.

Accidents and incidents were recorded and the appropriate actions taken. Events within the home were analysed to identify patterns. However, this information was not routinely used to learn lessons from events within the home. The registered manager told us they would begin using the information and share within the team.

People received their medicines safely, by trained staff. However, guidance was not in place for medicines people received occasionally. This meant there was a risk the medicines would not be administered consistently. The registered manager told us they would put the guidance in place.

There was a recruitment process in place and staff had received the necessary checks before commencing employment at the home. However, records were disorganised and not always kept in one place, the registered manager told us they would work to improve the system.

There was a lack of stimulation for people and social activities within the home. There were some bookings for external entertainers and parties within the home. We have made a recommendation about social stimulation and activities.

People had care plans in place for their care and support needs. However, these were not always updated as planned. People knew who to contact if they had a concern or wanted to make a complaint, the registered manager told us they knew how to address concerns raised. The provider had a complaints policy in place, however, it contained incorrect information about the management of formal complaints.

Safeguarding concerns were managed within the home and people felt safe living at St Bridgets Care Centre. People were supported to have maximum choice and control of their lives and staff supported the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People had enough to eat and drink and received access to medical and healthcare as required. Infection control procedures within the home were robust and the environment was clean, and free from clutter. Records were stored confidentially. People told us staff were kind and caring and they treated them with dignity and respect.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 17 May 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the management oversight of the home at this inspection. We have made a recommendation about social stimulation within the home.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.