St George's Nursing Home

St George’s Nursing Home is an adapted building providing accommodation, personal and nursing care to 19 older people at the time of the inspection. The service is registered to support up to 24 people. The service supports older people and people living with dementia across two floors and also provides nursing care. There are limited areas for communal access, and the service is adapted to meet the needs of people with impaired mobility and also has shared rooms which we looked into further.

Date of Inspection: We commenced this inspection on 23 July 2026 with a visit to the service. Due to the concerns found during our visit we sought assurance from the provider on 30 July 2026 and met with them on 05 August 2026 to share our findings and inform them of the actions being taken. The inspection was concluded on 8 September 2026. This inspection was undertaken in response to recent concerns shared with the Care Quality Commission (CQC).

Since our last inspection published on 15 January 2026, we found the service had not made the required improvements to meet the breaches of regulations and improve the standard of care provided to people. We found the provider was still in breach of 2 regulations in relation to safe care and treatment and good governance. We also identified new breaches of regulations in relation to safeguarding, staffing, medicines management, notifications to CQC of significant events and a poor overall culture.

There was not a proactive learning culture and risks to people were not managed safely. The provider did not follow local authority or CQC safeguarding procedures to ensure people were safeguarded from harm. Incidents where people experienced harm were documented by staff, but these incidents were not always responded to by managers. We identified ineffective monitoring and management of risks associated with dehydration, nutrition, and skin integrity. Records and observations showed some people remained in bed for prolonged periods without access to adequate food or fluids and without regular repositioning. This meant risks relating to dehydration, malnutrition, and the development of pressure ulcers were not consistently identified, monitored, or mitigated, placing people at risk of avoidable harm. The provider had not ensured enough trained staff were on duty to always meet people’s needs. Recruitment checks to ensure staff working in the service were safe to do so were not always carried out. People’s medicines were not always managed safely or administered at the times the prescriber intended. The provider did not ensure the environment was safe, and outstanding fire safety actions from our previous inspection remained outstanding. Staff did not complete regular fire drills or simulated evacuations.

Governance systems to monitor the quality and safety of the care provided were not effectively operated. The provider and management team failed to identify the issues highlighted during this assessment. We sought additional assurances from the provider to ensure the critical risks identified were being monitored regularly and people received care that was safe and appropriate. The provider had not worked in partnership with other health professionals within their community in a positive or proactive manner. A shared culture had not been embedded within the service by the provider to ensure people received appropriate care that met their needs fully. Leadership at all management levels did not support the delivery of safe care for the people using the service. We made referrals to help keep people safe during the inspection because serious concerns were found, including the local authority safeguarding team, commissioning team and the fire service.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

Following the feedback provided to the management team they have provided assurances that some action has been taken to address the shortfalls.

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.