St. Cecilia's Nursing Home

Updated 20 October 2021

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 Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

One inspector carried out this inspection.

Service and service type

St. Cecilia’s Nursing Home is a ‘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 looked at during this inspection.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We were unable to speak with people who were COVID-19 positive. Instead we looked at recent compliment cards completed by relatives and people who had returned home following their stay in the designated setting. We spoke with six members of staff including the provider’s representative, registered manager, deputy manager, one nurse and two care workers.

We reviewed a range of records. This included two people’s care records and multiple medication records. We looked at three 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 spoke with the local authority about the closure of the designated setting.

Updated 20 October 2021

About the service

St. Cecilia’s Nursing Home is a care home providing personal and nursing care to 35 people aged 65 and over at the time of the inspection. The service can support up to 44 people.

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

Due to a misunderstanding on the part of the provider, people living in the service were put at risk because in June 2021 the provider made a decision to move the previously approved Care Quality Commission (CQC) designated setting for COVID-19 positive people into a smaller setting. This smaller setting had previously been inspected by CQC in October 2020 and although it was approved as part of a larger setting, it was not intended to be used as a separate smaller setting. This five bedded setting did not meet the criteria for approval as it did not have sufficient infection prevention and control facilities. We have written to the provider separately about this matter. The five bedded setting is no longer to be used as a designated setting for people who have COVID-19.

Apart from our concerns about the five bedded setting, staff followed government guidance on the use of personal protective equipment (PPE). Equipment and the environment looked clean and hygienic and there had not been an outbreak of COVID-19.

Care plans and risk assessments were in place for people's support needs. These were reviewed regularly and covered people's health conditions.

The registered manager carried out regular checks and analysis of falls and incidents to ensure learning from events was undertaken. This meant risks to people's health and safety from repeated incidents were reduced.

People received their medicines on time and when they needed them. Staff had positive links with healthcare professionals which promoted people’s wellbeing.

Staffing levels were consistent, and staff were confident they could meet people’s needs. We observed staff being patient, kind and respectful towards people. Care was person-centred and staff had time to chat with people during the day.

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.

There was a registered manager in post: people and staff spoke highly of them.

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

Rating at last inspection

The last rating for this service was good (published 24 October 2018).

Why we inspected

We received concerns in relation to infection prevention and control (IPC)and the designated setting. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has remained good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St. Cecilia's Nursing Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.