- Care home
St James's Lodge
Assessment report published 30 December 2025
Contents
Ratings
Our view of the service
We carried out an assessment of St James’s Lodge on 21, 23 and 27 October 2025, concluding on 3 November 2025.
St James’s Lodge is a nursing home providing care for adults under and over 65 years, living with dementia, sensory impairments, physical disabilities and learning disabilities. At the time of our assessment, St James’s Lodge was not providing support to people with a learning disability. The service is registered to provide accommodation to a maximum of 38 people. At the time of our assessment 24 people were living at the service.
The assessment was prompted by concerns raised in relation to staffing, medication, hygiene and infection prevention and control. We looked at all 5 quality statements; is the service safe, effective, caring, responsive and well-led.
We identified the provider and registered manager were in breach of 4 legal regulations relating to dignity and respect, consent, safe care and treatment and governance.
People’s dignity and choices were not always upheld. One person told us they could not choose when to bathe; a bath rota directed staff on when people were to be offered baths. Prescribed net underwear was shared between people, which is undignified and institutionalised practice.
People’s rights under the Mental Capacity Act were not fully upheld. We found no mental capacity assessments or best interest decisions in care plans, despite several people being subject to Deprivation of Liberty Safeguards.
Some care plans lacked essential information. People’s repositioning needs were not always met, and records showed gaps of up to 5 hours between turns for those at high risk of pressure damage. Some end-of-life care plans were missing for people receiving palliative care.
Governance systems were not effective. Audits were not consistently completed or analysed for themes and trends. Action plans lacked timeframes and registered manager oversight. Provider level oversight was limited to electronic record checks, with no evidence of systematic monitoring.
People told us they felt safe, and staff were kind and caring. Most relatives were positive about the service and said they were kept informed about their loved one’s health and wellbeing. We observed some caring interactions and activities taking place. Staff were recruited safely, and most environmental checks such as fire alarms and legionella testing were completed.
We asked the provider for an action plan in response to the concerns found at this assessment.
In instances where the Care Quality Commission have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.
People's experience of this service
We spoke with 4 people living at the service, 2 health professionals and 6 relatives to help assess and understand how people’s care needs were being met. Most people living in the service were unable to verbally feedback their experience of the service to us. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
People shared mixed views about their experience at St James’s Lodge. Most relatives were positive about the care and support provided, describing staff as kind and compassionate. One relative told us, “Staff are lovely and always keep me updated about my mum’s health.” Observations confirmed staff interactions during activities and personal care were generally caring and respectful. However, there were periods when people were left without engagement, particularly after group activities, and some staff appeared task-focused rather than attentive to social needs.
Feedback about choice and independence was mixed. Some people had personalised rooms and communication aids. However, a structured observation (SOFI) showed 2 people spent long periods in communal areas with little interaction, although staff responded promptly to emergency call bells.
Overall, while people valued the kindness of staff and felt safe, improvements were needed to ensure care was consistently person-centred, dignified, and responsive to individual needs. This included addressing gaps in care planning, promoting choice, improving engagement, and ensuring systems for safety and quality monitoring are effective.