St Georges Lodge Residential Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well Led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. We identified a breach of the legal regulations in relation to good governance.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a clear shared vision, strategy and culture which was demonstrated by staff and put into practice.

Part of the provider’s Statement of Purpose notes, ‘Our mission is to deliver outstanding care and support by providing a positive culture that is person-centred, open, inclusive and empowering.’ Evidence gathered at this assessment shows the home has fallen short of this aim. Although we found instances of good care, there were occasions when people did not receive the high standard of care they were entitled to, as shown in this report.

The provider had inclusive leaders at all levels who understood the context in which they delivered care and support and embodied the culture and values of their workforce and organisation.

The home had been without a registered manager for over a year at the time of this assessment. However, a new manager had been appointed and was in the process of registering with the Commission. The manager had been supported to run the home with the assistance of a consultant employed by the provider and another member of the provider’s senior management team.

People spoke highly of the manager. One person said, “Yes, I know who the manager is. They come in. I saw the deputy manager today. She sat on the edge of my bed and we had a talk.” A relative told us, “She [manager] would deal with any issues. We can speak to her anytime.”

The provider fostered a positive culture where staff felt they could speak up and their voice would be heard.

Staff spoke positively about the manager and deputy manager. One staff member said, “I love it here. I couldn’t ask for a more supportive boss. Her door is always open.” Another staff member commented, “Yes, I can always go to [manager]. I was here when she started so I know her well. We have staff meetings every few months. We can talk about what we need or what we would like.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff’s diverse needs were acknowledged and catered for. For example, any religious beliefs were respected, and staff were allowed to work flexibly to accommodate these. If staff struggled to read, write or spell because of dyslexia, they were supported through their induction and training. One person told us, “I think the manager is good; she takes the happiness of staff seriously always.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

Issues found as part of this assessment had not been identified by the provider. Risk assessments had not been completed for people receiving blood thinning medication who were also at high risk of falls. Although the manager later compiled these risk assessments, they still did not fully identify what the risk was and how this could affect people. Some moving and handling practices we observed were unsafe. Staff recruitment systems were not robust. Medicines were not managed safely.

Monitoring charts completed by staff in relation to people’s hydration and bowel management had gaps in recording. These monitoring systems had resulted in a lack of oversight as they were not effective in managing people’s risks in relation to these areas.

We were sent a range of audits relating to the environment, cleanliness, health and safety and care plans. These audits enabled the provider to identify any areas of concern, and recorded actions that had been taken to drive improvement.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The service worked in partnership with a range of health and social care professionals. A healthcare professional stated, ‘The new manager is approachable, professional and highly responsive to communication. She replies to emails promptly, and provides clear, detailed updates regarding the residents I enquire about.'

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcomes and quality of life to people. They did not always actively contribute to safe and effective practice.

The manager was relatively new in post and displayed an enthusiasm and passion for their role. They had been supported by others in the running and management of the home. Whilst some lessons had been learned, for example, a staff member being present in the lounge to ensure people’s safety, other areas were in need of attention. An ‘Improving mealtime action plan’ from May 2025 stated people should be shown a plate of food so they knew what choices they could make. The same document stated menus should be put on each dining table. Another document stated, ‘Residents are not interrupted to take medication during meal time’. None of these recommendations had been put into practice. At lunchtime, we saw people were not shown a plated meal beforehand, menus were not on the tables, and people were interrupted by staff to take their medicine at the dining table (although at least 1 person chose to finish their meal first).