During an assessment under our new approach
Assessment activity took place between 7th October to 5 November 2025.
St George’s Nursing Home is an adapted building providing accommodation, personal and nursing care to 18 older people at the time of the inspection. The service is registered to support up to 24 people.
At our last inspection, published 15 February 2024, we rated this service as requires improvement.
There were breaches of regulation relating to person centred care, eating and drinking and the safe care of people. We asked for an action plan on how they would make the required improvements.
At this inspection we found there had not been enough improvement and the service remained in breach of regulation in relation to safe care and treatment. We found new breaches in relation to staff training and governance systems. The service has remained rated requires improvement.
The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident.
However, the information shared with CQC about the incident indicated potential concerns about the management of risk of people’s catheter care and identifying risk of sepsis. This inspection examined those risks.
The provider was previously in breach of the legal regulation in relation to person centred care and nutrition and hydration. Improvements were found at this inspection, and the provider was no longer in breach of these regulations.
We have asked the provider for an action plan in response to the concerns found at this assessment.
The governance systems needed development to ensure they were effective. We found there were shortfalls in the service that had not been identified and actions already in place had not been completed.
Staff knew how to recognise and report concerns relating to abuse. Most safeguarding concerns were reported appropriately. However unexplained injuries did not always follow the correct process such as investigation, record keeping and reporting. Medicines management systems and infection prevention control processes were in place. However, these areas were not always managed well.
People’s pressure care needs were not always met safely, and care records were not always accurate or consistent. This needed to be improved.
People, relatives and staff had opportunities for meetings and sharing their views. People’s choices were sought, and relatives felt they were supported in accordance with their wishes and needs. Relatives were involved with people’s care planning and reviews.
Mealtime experience was calm, and staff chatted with people. Staff checked on people to help ensure they ate well and enjoyed their food. However, we noted meals for people who needed different thickness levels were served at the same consistency, and staff were not clear on the difference. Most people ate in their rooms and a few people sat with lap tables in the lounge. People felt they had enough to do, and they had appropriate access to support services.
There were enough staff to meet people’s needs. People and relatives told us staff were available when needed and they were kind and helpful. Staff were positive about the service they provided, the management team and liked working there.