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 our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding, staffing and the way people’s medicines were managed safely.

This service scored 31 (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 proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Learning from accidents and incidents was noted and shared with the staff team. This was discussed at daily catch ups, supervisions and team meetings. However, this had not led to improvement for the issues identified in the home by the CQC, local authority and visiting health professionals prior to this inspection.

Staff recorded in people’s daily record of care provided, incidents, injuries, bruises and noted they had informed the management team of those noted. However, we found examples where actions had not followed staff reporting concerns and subsequently were not documented robustly, lacked investigation to identify if a person was at risk of harm and risks were not reviewed to mitigate future recurrence.

Staff told us learning from events, complaints and updates was shared through meetings and training. However, this learning had not been embedded into everyday practice or used to improve outcomes.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People received an assessment prior to using the service. Records were held as part of their care plan and information was to be shared with health and social care professionals when needed. This was used to help inform the care planning process. However, this assessment had not always been robust as the service had admitted people who they were unable to support due to complex needs. This resulted in failed admissions and people had been discharged to a different service or needed to go back into hospital.

People and relatives felt the move to the service had been good. A person told us, “My [family member] got the ball rolling and said they had found me a (new) place where I could have my own room. It didn’t turn out that way did it, now here I am sharing with them. When I arrived there was no discussion or anything they just showed me into this shared room and that was that. What they do for me is put a roof over my head and that’s about it.” However, another relative said, “[Person] has been here [number] of weeks, so far we are happy with everything.”

A staff member said, “There is a pre assessment by the manager and shared on the system so we can learn about that resident before they come. If from hospital we check the hospital discharge for any information / plans and check the drugs. We check skin, we check their observations we do their choking risks, this is one of the first ones we assess, then we do their Personal Emergency Evacuation Plan (PEEPS). Then we do the GP referral.” They went on to say decisions about people’s suitability to live at the home, and possibly share a room, and ensure their needs can be met by the home is made by managers.

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

Incidents and events that should have been reported to the local authority and to the Care Quality Commission were not. These included allegations of neglect raised by family members, concerns identified by visiting health professionals and unexplained skin tears and bruises. This was also an issue at our last inspection.

For example,1 person was found with a bruise to their face. Staff concluded the cause of this was unknown noting in the daily record, “It looks like [Person] has rested their head somewhere for long or might have hit the side of the face somewhere. As a result, we have notified management.” When we spoke with the home manager, they were not aware of this incident, or several other incidents placing this person at risk. The risk assessment and care plan for this person also had not been reviewed since the last recorded incident. Other examples of a lack of reporting included people being left in bed without personal care, food, fluid or medicines.

There were mixed views from people about if they felt safe using the service. A person told us, “Sometimes I don’t want to be here, sometimes the carers shout at me for no reason at all, but that’s life. They want me to go to the left and the right and if I am a bit slow, they shout at me. I can’t get my arm up and sometimes they are rough and it hurts when they pull me about. I have been in pain when they wash or help me get dressed a few times now. It’s not all the carers, the ones on today are good ones, but it’s the ones I don’t see so often. Sometimes they will leave a mark. Sometimes I’m feeling safe, sometimes I don’t.” Most relatives felt their family members were safe. However, a person told us they had been in altercation with another person living at the home. Another person told us the bruise they had was due to being struck by someone and a further person who suffered with anxiety was sharing a room with a person who at times was verbally abusive.

We could not be assured people were being protected from the risk of harm. Following the inspection, we reported our concerns to the local authority safeguarding and commissioning team. Following this the manager commenced reporting of issues identified past and present.

Staff told us they knew how to recognise, and respond to, abuse. Staff told us they would speak up and report concerns when needed. A staff member said, “If I see a safeguarding I will raise myself and report to the local authority. If nothing is done, I will go to the local authority and CQC.” However, as there were instances where concerns should have been reported and this had not happened, this did not assure us staff were putting their training into practice.

Staff received training in relation to safeguarding people from the risk of abuse and information was available to them and displayed around the home.

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.

At our last inspection we found people were not always supported safely with pressure care, safe eating and drinking, infection control and medicines. At this inspection we found these areas had not improved, and people remained at risk of dehydration, unintended weight loss, damage to their skin integrity and unsafe management of medicines. In addition, there were further safety concerns.

People had risk assessments based on their needs, but these did not give full guidance to help ensure staff supported people safely. This included pressure care management, eating and drinking, falls safety and risks related to health care needs.

Records reviewed showed care was not always being delivered in accordance with people’s needs. There were missed opportunities for repositioning. We reviewed the repositioning records for people assessed as being at high, very high or severe risk of developing or having a pressure ulcer currently. All records reviewed contained gaps in recording and/or evidence that people had not been repositioned in accordance with their care plans. People were not always supported appropriately with eating and drinking. We reviewed records of 3 people fully dependant on staff who were without food or drink for extended periods of time. These people needed staff to anticipate their needs due to frailty and complex needs, but staff told us they left them to sleep. This included during a heatwave and the increased risk of dehydration had not been considered.

Accidents and incidents were not effectively reviewed and mitigated. For example, a person who was high risk of falls was wearing poorly fitting footwear even though they were mobilising with (and without) a staff member and it being stated as a consideration in their care plan. There was also limited oversight of incidents due to staff recording in the wrong place, or due to a lack of action.

Bed rails were in use for all people except one. Assessments completed did not address the risks of using bedrails for people who could move in bed or mobilise. One assessment completed assessed bed rails as not being appropriate to use. Staff did not consider alternatives to mitigate the risk, and we saw this person in bed with the rails raised. There had been incidents where they had draped their legs across the rail and sustained a number of unexplained injuries.

People’s individual evacuation plans and the list of people in the fire grab bag was not up to date. It included the wrong number of people and the incorrect people currently residing in the home. For example, some people on the list had died and others had moved into the home but were not included. This presented a safety risk in the event of an emergency evacuation. The manager updated this while we were in the building.

People and their relatives gave mixed views about if staff supported them safely. A person said, “Sometimes they do, sometimes they don’t.” A relative of a person said, “My [Person’s] needs were always met by any member of staff, whilst also feeling safe.” However, another relative said, “I was visiting yesterday when a nurse came in with medication - 4 tablets were put in [person’s] mouth but NO drink. [Person] is unable to use a cup or reach one. Nurse left no conversation.” This person is known to need full assistance, a person we were concerned about and at risk of choking. We raised this as a concern with the manager and local authority safeguarding team.

Staff told us they knew how to support people in relation to risks. They were able to describe safe support with eating and drinking, pressure care, falls and health issues. However, the findings of this inspection raised concerns about staff knowledge consistently being put into practice.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We identified at our last inspection fire risks including gaps around the kitchen door frame where fire could spread. At this inspection, those gaps remained unrepaired and additionally the glazing panels in the double doors to the lounge were missing following an incident a number of weeks before. The fire risk assessment (FRA) had not been reviewed as required, regular fire drills were not being carried out, and a simulated evacuation had not been completed. The management team therefore had no assessment of how long it would take to evacuate people, staff and visitors the home in the event of an emergency.

One of the sluice room doors within the bathroom had become detached from the door frame and staff had not made this safe. Inspectors when opening this door found it fell on them. The door had been propped up back into the frame and posed a risk to any person or staff who may have unknowingly tried to open this door.

We raised these concerns with the provider and required them to address them as a matter of urgency.

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

We looked at 2 staff files to ensure they contained the necessary pre-employment checks including criminal records checks [DBS] to ensure staff were fit and proper applicants when employed. One file lacked references and a valid DBS check. We also found a visiting contractor working in the home. When we asked if they had a DBS check in place they told us they did not. At our last inspection we reported some staff did not have valid DBS checks in place. The manager removed the staff member and contractor from the service pending appropriate checks being put in place

Four staff had started work in April 2026; however, these staff had not completed their induction or training assigned to them and had completed only a limited number of training topics. Staff training overall was provided to care staff and nursing staff, which covered key areas such as safeguarding, moving and handling, nutrition and sepsis awareness. However, staff did not receive training of a sufficient level to support the varied and complex needs of people using the service. For example, staff were supporting people living with dementia, some physically resisted staff support with personal care, eating and drinking or day to day engagement. Staff had not received the specialist training required to enable them to provide this support safely and effectively.

Managers did not actively observe staff on the floor to ensure what was learned in theory was being safely applied in practice, for example supporting people living with dementia in a positive and supportive manner, attempting to reduce the frequency of refusals through consistent approaches by all staff.

During the inspection visit there were the numbers of care staff on duty the manager had assessed as needed to provide safe and timely care. However, 1 person required 1:1 staff to support them closely. Additional staff had not been added to the shift, meaning the staffing level for that day were 1 staff member under the assessed level required needed to meet people’s needs safely. Staff had told us some people did not receive personal care or served breakfast until late morning when they woke. The staffing arrangements in the home that day did not allow staff to wake people for medicines or food and fluid due to the management and oversight of the shift. Although people said when they asked for assistance staff provided this, staffing levels in the service placed people at risk of possible neglect and poor care.

Staff we spoke with told us they needed more of them to meet people’s needs safely and appropriately. A staff member said, “Staff is not to my liking, we are getting residents who have behaviours or need more care, so we rely on existing staff for the 1:1. We have that chaos in the system, I think we need 5 or 6 carers. 2 up, 2 down, 1 floating, one watching and observing. Now we have 4, so when [person] is awake, they have to look after them so leaves 1 down and 2 upstairs. If they have more then we can get to them quicker, earlier and when we need to.”

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.

There were Infection Prevention and Control (IPC) audits and checks in place to help ensure staff were following safe practice. We noted the home appeared clean and staff were seen carrying out appropriate cleaning tasks. In addition, staff used Personal Protective Equipment (PPE) including gloves. However, we noted a person who was using a catheter, their night bag was fitted, and the tubing was trailing on the floor throughout our observations despite room checks by staff. This increased the risk of contamination and could place the person at greater risk of developing a urinary tract infection (UTI).

Staff had received infection control training and told us they knew how to practice good infection prevention and control (IPC).

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

Covert medicines were administered without the appropriate legal consent to do so being sought. People’s medicines were administered without the appropriate, mental capacity assessment (MCA) best interest decisions or authorisation under the deprivation of liberty safeguards (DoLS). Clinical staff were not aware of who received their medicines covertly. When we asked the nurse in charge, they replied 1, however we identified a further person through this inspection they were not aware of.

People were not administered medicines at the times the prescriber intended. We observed during the inspection staff left people to wake as opposed to administering their morning medicines. One nurse said, “We decided they will sleep this morning; they missed breakfast and maybe will drop blood sugar or miss insulin. [Person] is someone who if we wake them, I wouldn’t say they are grumpy but will be difficult to manage. We will leave them until 11 and get them up.”

Nursing staff did not always visually check people had safely taken their medicine. For example, 1 person who took their medicines covertly the nurse said, “I wait for [Person] to have their breakfast, then when they have finished the staff let me know and I record it as given.” When administering medicines, the member of staff responsible is required to ensure the person has taken the medicine before recording it as administered. The nurse relied on information provided by other staff and did not directly observe whether the person had taken the full dose of their prescribed medicine.

Medicines records did not contain a body map for the use of topical pain patches. One nurse said, “It [the location] is recorded on the log so you need to see the previous day’s log, or you just go opposite from where you find it and use the other side. We don’t have a body map we have the daily notes.” It is vital to change locations frequently to prevent skin irritation, allow skin to recover, and ensure proper medicine absorption.

The medicines room temperature exceeded nationally recognised safe limits. Records showed over the previous 4 weeks the maximum temperature had been exceeded. This increased the risk medicines were not stored in accordance with manufacturers’ instructions, which could affect their safety and effectiveness.

People were not involved in planning or reviewing their medicines. Risk assessments in place in some cases had been reviewed in the early hours of the morning, when people were in bed. As required medicine protocols direct staff when to administer medicines that were not routinely prescribed. For example, medicines to manage pain or distress. We saw these protocols were not in place for anxiety, pain, agitation. As staff did not have appropriate tools in place for people to communicate their pain or distress, there was a risk people may not receive the medicine when required to ease those symptoms.