St Claire's Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, management of the premises and equipment and infection control.

This service scored 34 (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 proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Accidents and incidents had not been reviewed by the management team since August 2025, when the previous registered manager left. Accident and incident records showed some people had fallen a number of times. The provider had not reviewed these records to check for themes and trends and any necessary referrals made to the falls team. When incidents and accidents occurred, people had received medical help where needed. A staff member told us, “There are no meetings to discuss accidents and incidents. We have not had staff meetings since last year.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Information about people was not adequately monitored to ensure it was up to date and accurate. This meant people were more vulnerable if being admitted to another establishment such as a hospital, as the information that went with them may not have provided an appropriate picture of their needs. Although the provider used an electronic care planning system. This had not enabled the staff team to create hospital passports which would support clear information sharing when people needed them. A hospital passport helps people to give hospital staff and other services important information about them and their health when they go to hospital.

People were supported to maintain their health and attend appointments, both inside and outside of the service. Where routine health checks were undertaken people had support from staff who they know well to understand what was happening.

The service had maintained regular contact with local authority social workers. This included ongoing work with the GP practice and other health and social care professionals. Staff told us they escalated concerns to community nursing staff and to the GP when needed.

The provider did not work with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider’s safeguarding policy did not provide staff with the information they needed relating to how to report to the local authority and had not included contact details. The provider had not kept up to date with safeguarding procedures in the area and was not aware of the local authority safeguarding threshold tool which the local authority expects services to use. The provider’s training policy stated that staff would receive safeguarding adults and children training however staff told us they had only completed training in relation to safeguarding adults. Safeguarding children training was required because staff in the service come into contact with children as part of their work. We observed interactions between staff and people during our visits. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted. Staff had received safeguarding training. Staff understood their responsibilities to report a safeguarding concern. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times. Most staff told us they were confident to speak up if needed. A staff member said, “If there was abuse, I would report to [nominated individual], I would report to the local authority, consider the police and CQC as well as discussing it with the deputy manager.” A staff member told us, “I would not feel I could report abuse to seniors or [nominated individual], I would report it direct to CQC.” We identified some incident records which indicated that a person had been verbally aggressive towards staff and another person and this had not been identified as a safeguarding concern.

People told us they felt safe. A person said, “I feel very safe and happy here.” Another person told us, “I am safe and looked after.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. DoLS applications and authorisations were in place for people around any restrictions within their lives that they did not have capacity to consent to. The provider had no oversight of DoLS and had no systems in place to monitor and review these. A person had a condition on their DoLS which had not yet been met. A staff member had started to look at the condition and had put a risk assessment together as to how it could be achieved.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were not always robust and did not provide clear guidance to staff on how to work with people and how risks in relation to health and social care could be mitigated. Some people had a diagnosis of epilepsy. There were no epilepsy care plans or risk assessments in place for people who had epilepsy and no instructions for staff in relation to potential seizure triggers, type of seizure activity that was usual for the person, what actions to take and when to escalate. There were no risk assessments in place relating to day-to-day activities like showering, bathing, going out and no mention of SUDEP (Sudden Unexpected Death in Epilepsy) or risks of injuries from falls. Staff training records showed that most staff had training, however a staff member told us they would not know what to do in the event of a seizure and told us they would put the person in the recovery position during a seizure which could put them and the person at risk of injury.

People who were at risk of pressure injuries were not always repositioned in line with their care plans which increased the risks of injuries deteriorating. People’s emotional support care plans and risk assessments did not always provide guidance for staff on what action they should take to support people when they became anxious and distressed. People who were at risk of constipation were not always effectively monitored. This meant we could not be assured that they had been provided with ‘as and when’ required laxative medicine or foods which have a laxative effect when they needed it.

People’s choking risks had been assessed. Some people had been seen by the Speech and Language Therapy teams (SaLT), and modified diets had been recommended. We saw people receiving modified food during meals which showed that SaLT guidance was being followed.

Personal emergency evacuation plans (PEEPs) were in place in the service to detail people’s support needs if they needed to be evacuated in an emergency. However, these were not always complete and had not always been updated when people’s needs had changed and had not been amended when people had moved rooms. The list of people living at the home used by staff in emergencies (these were located next to each fire exit) had not been updated since February 2026. This meant it listed people living in rooms who were no longer living at the service and new people who were not listed. This put people at potential risk of harm if there was a fire.

Some people were prescribed blood thinning medicines which increased the risk of bleeding. Risk assessments were in place for staff about handling the person gently or what specific things to observe for, such as bruising, blood in the urine or what action to take if they sustained a cut or bruise.

People were supported to move around the service safely and were supported to spend time where they chose. Staff told us about safe ways of working with people which demonstrated they knew them well.

The provider did not detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care.

Some building related checks and tests had not been completed regularly to keep people safe from harm. We found a cleaning cupboard which contained chemicals open and unlocked. We reported this to staff and asked them to ensure it was locked to keep people safe from harm.

We observed damaged flooring, holes in the floor under carpeting and holes in carpets. These issues presented a hazard to people and staff and could contribute to people falling. One area of the service was particularly bad, the provider told us this was planned to be renovated. They had told the local authority commissioner the same in April 2026, however no action had been taken to address this. Areas of the service already renovated were also noted to have had damaged flooring. Some areas of the service had radiators which were not suitably covered which put people at risk of burning themselves. The provider’s records did not show that these radiators had been checked frequently (when working) to ensure that their temperatures were safe and that the valves fixed to the radiators were working correctly.

The fire service had visited the service in May 2023 and issued a deficiency notice. Some deficiencies identified in 2023 remained outstanding, which evidenced timely action had not been taken to reduce fire risks. We observed fire doors around the service propped open with furniture, equipment, door wedges and toys which would prevent them closing in the event of a fire. The provider had not maintained an up-to-date list of people living at the service and their location in the service to aid fire evacuation. We reported our concerns to the fire service.

Kitchen equipment was not fit for purpose, the microwave was rusty and the dishwasher had not worked for several months meaning kitchen staff had to wash everything by hand. Food was taken to the lounges and dining area by trollies which were not heated, which meant food cooled down on route to the areas and it did not retain its heat when being served. After the assessment the provider told us they had ordered a new dishwasher, and this was being delivered on 12 August 2026.

Water temperatures had been checked frequently, however the checks on thermostatic mixer valves only showed that water temperatures had been checked in communal bathrooms and in sinks in people’s bedrooms. Some rooms had ensuite shower facilities, the showers had not been checked. This meant the provider could not be assured that the water was at a safe temperature. A person told us they could not use their shower as it was too hot. The maintenance person checked it and confirmed it was too hot to touch. On day 2 of the assessment the shower was changed. Providers are required to flush water from empty rooms and outlets rarely used on a weekly basis to prevent the build-up of legionella in the pipes. We observed that there were no records of water flushing being undertaken in vacant rooms at the service and maintenance staff confirmed this was not done. This put people, visitors and staff at potential risk of harm from Legionnaires’ disease.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff reported there was not enough staff to meet people’s needs safely, particularly at night when only 3 staff members were on shift to cover across 4 floors. Many people required 2 staff to support them with personal care or repositioning which left 1 staff member alone covering 2 floors. A staff member said, “On nights there is not enough, because they are covering across 3 floors. No one is on the lower ground floor, [Person] wanders on this floor at night so someone has to keep going down there.” After the assessment the provider told us they had put another staff member on the night shift in response to this.

People told us there were not always enough staff. Comments included, “Sometimes there is enough staff, but sometimes not” and “I think they could do with some more they are always so busy.”

We observed there appeared to be enough staff to meet people’s basic needs during the day, there were very limited activities taking place, staff were too busy to be able to do structured activities as well as care and support. It was unclear how the rota was put together to ensure the needs of people (their dependency rating) were met. The provider told us after the assessment that an additional staff member would be rostered to work during the day, further care staff would be recruited, and they will review the dependency rating making sure enough staff were deployed to meet people’s needs.

The provider’s training policy set out mandatory and additional training requirements for staff. Some staff told us they had not had face to face moving and handling training or a review of their moving and handling competency for some time. Most staff had attended training to meet people’s needs. Some newer staff were still undertaking training. Some staff told us they did not feel supported. There was no Parkinson’s disease training listed despite staff caring for and supporting people living with Parkinson’s disease. Staff responsible for producing food, serving food and assisting people to eat had not completed training around The International Dysphagia Diet Standardisation Initiative (IDDSI) framework, staff did not know about IDDSI and what the terms meant. This put people at risk of receiving food at the incorrect texture and increased choking risks. We did not see people being given food that did not meet their assessed needs.

Despite staff employment records detailing that staff would receive regular supervision meetings these had not been taking place. Staff told us supervisions had not been taking place since the last registered manager left in August 2025. A staff member said, “We have been without a manager for a year now, it is really difficult.”

Staff had been safely recruited. All required checks had been carried out, and documents were all in-date. The information helps employers make safer recruitment decisions.

The provider did not assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We observed the service was not clean. On day 1 of the assessment, carpets were very dirty and sticky, handrails, door frames, handles and switches were visibly dirty and sticky to touch. There was a lack of suitable bins to minimise the risk of infection and contamination in the bathrooms and toilets. There were no paper towels in some toilets which meant people could not dry their hands effectively after using the facilities. The provider’s infection, prevention and control (IPC) policy did not provide staff information as to who is responsible and who to report IPC concerns to. We reported this to the provider, who told us they had employed 3 cleaners in the service, and stated that it was not dirty. On day 2 of the assessment, the carpets were cleaner and no longer sticky, the maintenance team member had cleaned the carpets after we had left on day 1. However, immediate cleaning did not address wider IPC failings.

A health and social care professional told us, “The cleaning and premises needs a lot of work, downstairs and upstairs in particular.” Another health and social care professional said when they visited the carpets were dirty and had a malodour. Before the assessment, a relative told us their loved one’s bedroom was, ‘In need of a deep clean and repair and redecoration. The odour on entering at times can take one’s breath away.’

The provider told us they had a daily cleaning programme in place. The service employed housekeeping staff to carry out daily cleaning. Cleaning schedules were not always completed to show what cleaning was taking place. A cleaning schedule showed there were monthly deep cleans of people’s rooms were in place. Infection control audits were completed regularly; however, these did not detect the issues found during our assessment. People told us, “The cleaning staff come in and clean my room. My room is always fresh and tidy, which is how I like it” and “The staff do the cleaning when they can get in my room.”

The provider had plenty of PPE (Personal protective equipment) in place to keep people and staff safe. Staff told us they had sufficient equipment and PPE to provide safe care. We observed staff handling and serving food were not always wearing PPE according to the task. Staff had received infection prevention and control (IPC) training.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. However, we observed that the medicines rooms were too hot to store medicines. Only 1 of the rooms had a fan which was in use but circulating warm air. Failure to keep medicines consistently stored at the safe maximum temperature set by medicines manufacturers could increase the risk of medicines being stored outside their recommended ranges, potentially compromising their quality and efficacy. This put people at risk of harm.

Medicines administration records (MAR) were in place and staff signed these to evidence they had administered prescribed medicines. Where MARs were handwritten, they were not always double signed to show they’d be verified as correct in line with good practice guidance.

Medicines were stored securely; the medicines rooms were clean and organised. Appropriate procedures were being followed for medicine disposal. MARs records were complete and audited and totals in stock matched records.

People told us they received support with their medicines. Comments included, “I always get my medicine on time” and “Medication is sorted by the staff, they make sure I take it.”