St George's Nursing 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 the last inspection, we rated this key question as requires improvement. At this inspection this key question remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 41 (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 always 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.

We found the provider had not taking the appropriate learning from the previous inspection and visits from external assessors or agencies. Action plans in place from these were not fully completed or embedded.

People were not able to tell us if their views were asked for. Relatives told us the management and staff team asked for their views and took any action that may be needed. They said feedback and updates were shared with them.

Staff told us learning from events and updates was shared through meetings and handovers. A staff member said, “Outcomes and actions of inspections are always shared. Updates on policies and legislation changes are given. However, lessons from complaints are not always shared.”

Learning was taken and shared with the staff team. This was discussed at handovers, team meetings and sent through a messaging system to the relevant team. However, this was not always effective, as there was evidence of learning not embedded.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Most people were not able to tell us about their move into the home. A person who was able to share their views said, “It was all done for me as I needed to move in somewhere to leave the hospital.” Relatives felt the move into the service had been positive. A relative told us, “I was worried when I first had to make the decision to put my [person] in a nursing home and because the building is quite old and looked run down I was worried but I cannot praise the staff enough they were very welcoming in a very difficult time.”

Health and social care professionals told us the team worked with them to help ensure people received the right care.

People received a preadmission assessment prior to moving in. Records were held on file and information was to be shared with healthcare professionals as needed. These assessments would benefit people more if they were more holistic and ensured they captured all information important to people.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

There were a number of unexplained bruises and skin tears on people documented. However, there were no records of investigations, safeguarding referrals or notifications regarding these. The manager told us these were discussed at the time with the staff team, and an explanation was provided. However, they acknowledged this process had not been robust and did not follow local safeguarding processes.

We had received no safeguarding notifications from the service since March 2025.

Despite these concerns people told us they felt very safe living at the service. Relatives also felt their family members were safe. A relative said, “I feel [person] is safe.”

Staff told us they knew how to recognise, and respond to, abuse. A staff member said, “I would whistle blow if I had any concerns with regards to a service user's safety to the relevant authorities.” Staff told us they would speak up when needed.

Staff were observed being kind in their approach and gentle when supporting people. People were relaxed and comfortable with staff.

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.

Staff told us about risks to people and the action they took to help reduce those risks. For example, in relation to dietary needs and pressure care. However, they also told us that everyone who had modified foods had this at the same thickness. Records showed that people required different levels of thickness. The manager told us they had identified this area as a training need, and this was booked for November 2025.

Staff did not support people to reposition in accordance with their care needs. We reviewed 5 people’s repositioning records and found people were not repositioned in accordance with their care plans and needs. For example, people were often left in the same position longer than they should have been and also at times repositioned onto the same area they had previously been on. This increased the risk of people developing skin damage and reduced the ability of the skin to heal where skin damage had already occurred.

During our visit we saw staff assisted some people to sit up when eating. However repositioning records reviewed did not always include that people had been sat up at mealtimes in line with their care plans, risk assessments and safe practice. The manager said they carried out checks at mealtimes, and they had not seen anyone laying down while eating. However, we discussed the importance of ensuring records were accurate.

People had individual risk assessments, and they were regularly reviewed in most cases but despite this some included conflicting information. For example, guidance for staff that a person was to be repositioned 2, 3 and 4 hourly.

Due to the risks to people’s safety, this was a breach of Regulation 12 of the Health and Social care Act (Regulated Activities) 2014.

Most people were not able to express their views in relation to if they felt care was delivered safely. A person who was able said, “So far, so good.” However, this inspection was prompted in part due to some concerns shared with the Commission about unsafe care. We found some of the same concerns.

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.

The provider had not completed actions following a fire risk assessment completed in June 2025. These included fire drill attendance, intumescent strips (seals which prevent smoke and fire spreading) on doors and ensuring hazards were not in corridors. Following our feedback fire drills had commenced and environmental risks were addressed.

The provider had not completed monthly health and safety checks. These included fire safety checks, water temperature and window restrictors. The manager told us they had been without a maintenance person to carry out these checks until recently. We discussed the importance of having staff members able to carry out these checks rather than relying on 1 person.

Staff told us they had not all attended fire drills. Those who had said it was some time ago.

The provider had not ensured rooms and trolleys with harmful substances were secure. We found the sluice rooms were unlocked and cleaning trolleys were left unattended. This meant harmful cleaning products were accessible to people who were vulnerable. Following our feedback locks were fitted to sluice rooms and staff were reminded about not leaving cleaning products unattended.

Due to the risks to people’s safety, this was a breach of Regulation 12 of the Health and Social care Act (Regulated Activities) 2014.

People had individual evacuation plans. An evacuation sledge was installed at the top of the stairs and firefighting equipment was in place.

The building had only 1 small lounge/dining area. This could only accommodate 4-5 people in the lounge and 5-6 people at the dining tables. While most people were in bed, there would not have been room for them to enjoy the communal area if they chose to get up.

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

The provider had not ensured staff completed mandatory training. We reviewed staff training records and found gaps in staff training in key areas of care they provided. This included catheter care and sepsis awareness. In addition, many areas of training updates were missed and or overdue. This included fire safety, first aid, manual handling, IPC, medicines administration and safeguarding. Our observations and review of records found that these training updates were essential.

This meant people were not always supported by staff suitably trained and skilled for their role and placed people at risk. Therefore, this was a breach of Regulation 18 of the Health and Social Care Act (regulated Activities) 2014.

People who were able to share their views said there were enough staff to meet their needs. A person said, “I’m getting the help I need.” Relatives said they felt there were mostly enough staff, and staff were trained for their role. A relative said, “I do feel the staff are well trained to take care of my [person].”

Most staff said there were enough of them to meet people’s needs in a timely way. A staff member said, “There is mostly enough staff to meet service user’s needs, and times (busier) when staff is low due to bed occupancy levels.”

Staff felt they received enough training and support to carry out their role. A staff member said, “Over the years I have been with the nursing home I have received enough training, my competency has been checked, and I receive regular supervision from the line manager.”

Staff were visible and prompt when people requested support. Staff were taking their time when supporting people and carrying out regular checks.

Recruitment followed a process carrying checks to ensure staff were suitable to work in a care setting. These checks included criminal record checks, verifying applicants’ identities and written references. However, we found that a person appointed to carry out maintenance works and checks in the home has started working in the home in June and only received a DBS when we had followed this up as part of our inspection. We also found that 1 of the 3 recruitment records reviewed had employment gaps not explored. Employees are required to explain any gaps in employment, and this must be documented by the employer.

The provider did not always 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.

The provider had not ensured there were areas for staff to wash their hands. Staff were using a sink in a person’s bedroom to wash their hands before mealtimes. There was no assurance the area had been cleaned since providing personal care. In addition, communal bathrooms had people’s toiletries in them which meant there was a risk staff were sharing toiletries when supporting people. Following our feedback a new sink was purchased and due to be installed and checks were in place to ensure toiletries were not being left in bathrooms.

People’s bedrooms and communal areas were kept clean. There were no malodours.

Staff told us they knew how to practice good infection prevention and control (IPC). A staff member said, “I have been trained on control measure and to maintain hygiene in our home.”

There were IPC audits and checks in place. However, these had not identified the concerns we found as part of our assessment. Following our feedback the manager had introduced additional checks to cover these areas.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not involve people in planning.

At our last inspection we found shortfalls with the management of medicines. This included the way medicine patches were recorded and the administration of time sensitive medicines. At this inspection, staff were still not recording the administration process for patches safely. This had not been identified through the provider’s audits and checks.

In addition, we found the medicines room to be unlocked which meant medicines were accessible to those not permitted to have access which included people who used the service and were not always supervised.

We also found time sensitive medicines, were not always given at the same time and this had not been identified by the audit process.

This was a continued breach of Regulation 12 of the Health and Social Care Act (regulated Activities) 2014.