Working at St Cecilia Care Home

Not enough staff properly checked to keep people safe all the time, leading to rushed mealtimes and people left unattended like with skin tears.

Feedback about staffing levels was mixed. A relative told us, 'Mealtimes, I find the atmosphere difficult, not very inviting all a bit rushed and hectic'. We also observed a person with an unattended skin tear walking about the home.

Risks like falls and infections not fully managed, with no checks on patterns in accidents to prevent repeats.

Records of incidents, accidents and falls were recorded, although there was no system in place to look for trends, identify any learning, and reduce the risk of an incident happening again. For example, where a person had several unwitnessed falls over a period there was no analysis of the falls.

Leaders not doing proper checks or audits to spot and fix safety and quality problems.

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.