St George's Nursing 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 the last inspection, we rated this key question as requires improvement. At this inspection this key question has remained 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.

This service scored 54 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. However, quality assurance systems did not always identify where there were shortfalls in achieving these outcomes and we found examples where not all staff behaved in a way that reflected the expectations of the providers own values and culture within the service delivery.

Staff were positive about how the team engaged in helping people live their best lives. A staff member said, “The good thing about our service is we are dedicated, compassionate, problem-solving and a positive attitude towards carrying out our tasks. The hours for our 1:1 resident being reduced or taken off, we were told this is because of funding.”

Staff were positive about the culture and approach in the home. They told us they would have a relative of theirs in the home. A staff member said, “Generally, I think St Georges is a good service provider.”

Feedback from people and their relatives was obtained through meetings and surveys. Meetings were held with staff to share information.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The provider’s action plans were not clear or robust to address the issues within the service in place. These managed areas identified by the team as needing improvement and also shortfalls identified by external agencies. However, action plans were not clear or robust and did not capture an overview of the service. As a result, this meant actions were missed and areas didn’t improve quickly enough.

The manager was new to their role having worked as a clinical lead in the home for a number of years. There had been some time where the new manager was without the support of a clinical lead in the home. A new clinical lead had been appointed in October 2025. The new manager acknowledged there was work to do to improve aspects and care and support for people and ensure staff had the right skills and support for their role.

Staff we spoke with and received feedback from were positive about the new manager and the changes they were implementing.

The provider fostered a culture where people felt they could speak up, and their voice would be heard.

Staff were positive about how the management team engaged with and involved them. A staff member said, “I am able to speak freely and given the opportunity to share my views.” Staff told us the management team were visible and approachable.

There were also staff surveys. There had been 7 responses, but these were positive.

There were resident, relative and staff meetings recently introduced. These covered key subjects in the home.

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.

Staff felt supported and respected by the management team.

Staff employed demonstrated different backgrounds, ages, genders and ethnicity which was a benefit for the people they supported.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There were governance systems to help identify and address any issues. These systems covered key areas such as care plans, falls and medicines. Where issues were found, a plan was implemented and actioned to resolve it. However, these systems were not robust. We found several ongoing issues that had not been addressed and also additional shortfalls that had not been identified. These issues included concerns in relation to safety and environmental concerns, risks to skin integrity, staff training and robust recruitment processes, promoting dignity, care plans and record keeping, medicines management, robust oversight and reporting of unexplained injuries and unclear information in relation to people’s dietary intake. These shortfalls placed people at risk of harm and receiving care below a standard required.

This was a breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Staff were positive about the management and running of the service. A staff member said, “Regular spot checks are carried out by the manager and nurse on shift.”

We found the manager responded to any complaints, feedback and requests.

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 manager was keen to work well with the local authority, external services and the CQC. While the manager was open and took feedback from external partners and communities, there was little progress made in areas that had been identified. However, they were keen to make the needed improvements and ensure people had a safe environment and were happy.

People who were able to share their views, and their relatives, told us they were supported to access other professionals.

A visiting health and social care professional told us they felt people were appropriately cared for. They told us staff followed their advice, including when there had been an issue where care had fallen below the expected standard.

The service was registered with a local care providers association to access training and updates, and other health and social care teams so health care and support were accessible.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There was a lack of learning and improvement within the home. Issues identified through external agencies such as CQC, local authority and a fire risk assessor were not addressed. Action plans were not consistently completed or robust to allow tracking of progress. As a result, there were gaps in safety and standard of care.

There were limited plans for new or innovative systems. The manager was new to their role and was working to comply with the required standards.