19 August 2022
During a routine inspection
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.