St Claire's 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 assessment 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.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 46 (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 based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Staff told us that the culture of the service has been poor, they told us they had not had a registered manager for 1 year. The provider had not held meetings with the staff or provided them support through regular supervision sessions in the absence of a registered manager. Comments from staff were mixed, “This team does not have a problem with the culture, they are really good, respectful and passionate” and “There is no communication I feel the whole communication system is bad.”

The provider’s statement of purpose detailed, ‘Within the Home, there are various systems, which ensure that close monitoring is maintained on all of the Home’s services and procedures. Through staff supervision, observation, and regular reviewing, attention to the smallest detail is pivotal to everything that we do. An important part of our quality programme is to involve the Residents and their relatives. We regularly ask for comments on the Home, the staff and services we provide. We also annually circulate a Resident questionnaire, which assists in assuring that we continue to provide a quality service.’ However, we found this was not always achieved in practice.

Since the assessment site visits the nominated individual for the provider told CQC that they plan to make improvements to the service.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. There was no registered manager in post when we carried out our assessment. The previous registered manager had left in August 2025, which meant there had been 11 months without a registered manager. The provider told us they had not made arrangements to recruit a new manager for the service. During the assessment, the nominated individual for the provider gave us conflicting information about the management arrangements. They said they would apply to be registered and then they told us they would recruit a new manager. After the assessment the provider told us they had received applications for a manager and would be interviewing in the near future.

People did not always feel they could speak up and that their voice would be heard.

We received mixed feedback from staff in relation to reporting concerns to the provider. Some staff felt they could report concerns and be listened to and others told us they did not have confidence in reporting concerns. Staff told us how they would escalate concerns outside of the organisation if they needed to. The provider’s whistleblowing policy directed staff to contact CQC if they had concerns.

Staff confirmed they had not had staff meetings since the last registered manager left.

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. There was a diverse workforce. There were informal arrangements in place to support flexible working to support staff with childcare and health appointments. However, some staff reported they had not always been dealt with in a fair and appropriate manner, they felt they had not been listened to, had not been treated well by the provider, which left them feeling unsupported.

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, or share this securely with others when appropriate.

The provider’s audit systems had not been robust. Whilst some audits of the service had been undertaken by staff, these had not highlighted the significant issues with the environment, infection control, and deficits with care plans, risk assessments and records.

The provider had failed to complete checks and provide support to the service to ensure it was safe and effective. After we fed back concerns to the provider, they commissioned an external compliance organisation to complete audits. They told us the support was due to start on 20 August 2026. At our assessment we found significant concerns which evidenced the provider had not taken timely and robust action to improve the service.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We found that the provider had not understood the regulations and had failed to tell CQC about an incident when a person left the building and was found by members of the public in the community. CQC contacted the provider when we became aware of the incident and asked the provider to submit the relevant notification, which they did.

Some people's personal records were stored securely including on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so. Some records around the service were observed to be in piles around the offices. Care notes were not always complete and accurate to enable the provider to monitor people’s care and treatment.

The provider had displayed their last inspection rating within the building, however this was only accessible to visitors as it was displayed in an area where people were not able to access.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The staff worked hard to build and maintain relationships with health professionals, working in collaboration with other services to ensure good, joined up care for people. The service had developed partnerships with 2 sets of external entertainers who supported some activities, the local authority and through links with GPs.

The provider had not always focused on continuous learning, innovation and improvement across the organisation and local system. They had not always encouraged creative ways of delivering equality of experience, outcome and quality of life for people or actively contributed to safe, effective practice and research.

The provider told us they attended support networks with other registered managers, such as local authority forums and gained support from organisations such as skills for care. However, it was not clear how the provider had used the support from these networks to drive continuous improvement in the service.