St James's Lodge

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 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.

The service was in breach of legal regulations in relation to safe care and treatment and good governance.

This service scored 56 (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.

Since our last assessment, we found there were now systems and process in place to review and learn from accidents and incidents within the service. However, some of the records relating to this were not consistently completed. For example, the compliance manager ensured incidents and accidents were reviewed. However, the registered manager had failed to accurately complete all of the recording tools used to monitor concerns such as falls. This meant there was a risk key information would not be used in the evaluation of all adverse incidents and accidents.

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.

There was a procedure for staff to follow before people were admitted to the home. This included a pre-admission assessment to establish a person’s needs. The provider undertook this in collaboration with the relevant funding authority and healthcare professionals, where appropriate. Care records showed where healthcare partners had been involved in people’s care and treatment to improve outcomes.

If a person needed to be admitted to hospital or transferred to another service, information about their medicines and health and care needs could be provided.

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 bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

The provider had ensured staff had received training in safeguarding and staff understood how to escalate and report concerns. However, during our assessment, we identified the registered manager had failed to appropriately report a safeguarding incident when an error relating to controlled drug administration had been identified. We spoke with the compliance manager about this, and a safeguarding alert was immediately raised with the local authority.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

Since our last assessment, the provider had introduced systems and processes to monitor approved and pending DoLS applications. There was a tracker in use that showed where DoLS had been approved and others that were pending with the relevant local authority.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s care plans were not always accurate, sometimes contained contradictory information and lacked detail around specific conditions. For example, including but not limited to, risks of falls, mobility needs and pressure area care. We found some corresponding care plans did not always reflect the information recorded in risk assessments. This meant staff did not always have clear and consistent guidance on how to support people safely. This increased the risk of people not receiving the care they required in a timely way, placing them at risk of a deterioration in their health and wellbeing.

This contributed to the continued breach of regulation in relation to safe care and treatment and good governance.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider undertook regular audits to monitor the safety of the home environment and equipment. Mobility, fire equipment and emergency lighting were tested regularly to ensure it was in good working order. There were also water temperature checks, legionella testing, gas safety certificates, electrical hard wiring and portable electrical appliance tests. Improvements had been made since our last assessment in relation to the completion of fire drills. Records showed these were now routinely completed. The fire risk assessment in place had been reviewed in September 2025.

People had individual Personal Emergency Evacuation Plans (PEEPs) to aid them in being safely evacuated from the service in the event of an emergency.

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 received mixed feedback from people and staff around staffing levels at the service. People told us that staff were very busy and there could be delays in receiving care, however others did not raise concerns. Staff told us they were significantly understaffed and it had an impact on people’s care. One said, “The understaffing is 100% impacting the residents. Obviously getting up in the morning and going to bed, so some people are not getting up when they want so we have to tell them they will have to wait.”

The registered manager often started work in the afternoon so was not present to lead staff through the peak times of the day where staff required leadership, direction and support. The registered manager told us they used a dependency tool to aid in calculating staffing levels; however, this had not been updated since April 2026. We fed back the concerns we received to the provider.

There was an induction in place for new staff, and we saw records to support this were completed. The provider had a continuous training programme in place for staff who confirmed they received training. Staff received supervision and appraisal to support them and develop them in their role. Staff were recruited safely with appropriate checks taking place to ensure their eligibility to work and suitability to work with vulnerable adults.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed the environment was clean and there were no malodours present. Staff were seen wearing appropriate Personal Protective Equipment (PPE) when required and used it correctly, demonstrating good awareness of infection prevention and control practices. Staff had received training in Infection Prevention and Control. There was sufficient PPE available for staff throughout the service. No concerns were raised by staff, people or their relatives about the cleanliness of the environment.

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

We saw some people’s Medicines Administration Record Charts (MARs) had been completed in advance of medicines being administered to them on the day of our site visit. This meant that people’s MARs may not always be an accurate reflection of what medicines had been administered. Therefore, we could not be assured that people always received their medicines in the way prescribed for them.

Record keeping was not consistently accurate or complete. Medication profile sheets did not always reflect current medicines, and there were discrepancies between profiles and MARs. Allergies were not consistently recorded on MAR charts. Some people’s MARs were not clear and there was no system in place for ensuring handwritten records were accurately and correctly transcribed. These issues can potentially increase the risk of medicines errors.

When medicines with a variable dose were prescribed, the actual dose administered was not always recorded. For example, for medicines used to manage pain or for the relief of constipation. Without this information we could not be assured if peoples pain or constipation was being managed in line with the prescribers’ directions.

This contributed to the continued breach of regulation in relation to safe care and treatment and good governance.

There had been improvements to the way Controlled Drugs were managed and administered since our previous assessment. We observed medicines being given in a safe and caring way at lunchtime. We spoke with 2 people who told us they were happy with the way they received their medicines, and they got them at the right times.