• Care Home
  • Care home

St Cecilia Care Home

Overall: Requires improvement read more about inspection ratings

1 Hitchen Lane, Shepton Mallet, Somerset, BA4 5TZ (01749) 342809

Provided and run by:
St Cecilia Care Home Limited

Important: The provider of this service changed - see old profile

Latest inspection summary

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Background to this inspection

Updated 15 March 2023

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.

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

The inspection was carried out by 3 inspectors over 2 days and was supported by an Expert by Experience for 1 day. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

St Cecilia Care Home is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. St Cecilia Care Home 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

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

Notice of inspection

The inspection took place on 11 and 12 January 2023 , it was unannounced on the first day and announced on the second day.

What we did before the inspection

We reviewed information that we held about the service such as notifications. These are events that happen in the service that the provider is legally required to tell us about. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with 6 people who used the service and 3 relatives. We spoke with 7 staff, which included the registered manager, the provider, 1 senior care staff, 2 carer's and 3 domiciliary staff. We undertook observations of people receiving care to help us understand their experiences. We reviewed a range of records. This included 4 people’s care records and 2 medicine records. We looked at 2 recruitment files and 1 agency profile. A variety of records relating to the management of the service were reviewed including, accident and incident records and audits. We sought feedback from professionals who work with the care home.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Overall inspection

Requires improvement

Updated 15 March 2023

About 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