11 January 2023
During an inspection looking at part of the service
St Cecilia Care Home is a residential care home providing care and accommodation for up to 17 people in one adapted building. At the time of our inspection there were 11 people living in the home
People’s experience of using this service and what we found
The service did not have robust systems in place to monitor the quality and safety of the service. Systems that were in place were not effective and had not identified the improvements that were required. The provider visited the home regularly, but no formal audits had been completed to identify any shortfalls and to monitor any actions identified.
The service did not have a way of assessing the staff numbers it needed to keep people safe. We have made a recommendation about staffing.
Staff followed infection prevention and control measures. Medicines were managed safely. Staff knew how to recognise, and report abuse.
The provider had appropriate recruitment procedures in place to ensure staff employed by the service were safe to work with vulnerable adults.
Relatives told us communication was good with the service and they were satisfied with the support their relatives received.
People and relatives told us people felt safe with the care and support they or their relative received. People and staff were positive about the registered manager.
The service worked in partnership with health and social care professionals.
People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at the last inspection
The last rating for this service was good (published 21 May 2018).
Why we inspected
This inspection was prompted by a review of the information we held. This was a focused unannounced inspection covering the key questions of Safe and Well Led. This report only covers our findings in relation to the Key Questions Safe and Well-led.
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.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection. We found evidence the provider needs to make improvements. Please see the Safe and Well Led sections of this report. The provider took action during the inspection to mitigate the risks.
Enforcement and Recommendations
We have identified breaches in relation to assessing, monitoring and managing risks to people, governance and quality assurance systems at this inspection. We have made a recommendation about staffing levels.
Please see the action we have told the provider to take at the end of this report
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for St Cecilia Care Home on our website at www.cqc.org.uk