Archived: St. Catherines Residential Care 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.

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

The provider was in breach of legal regulation in relation to people’s safe care and treatment.

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 culture within the service was not focused on safety and learning. Some known risks to people’s health and safety were not assessed or mitigated. This included risks associated with the handling and administration of people’s medicines. The provider’s systems for the review and investigation of accidents and incidents, to ensure learning from these, were not effective. Some incidents affecting people’s health, safety and welfare were not recorded, reviewed or thoroughly investigated. Lessons were not learnt to continually identify and embed good practice. We saw when incidents involving people had occurred, some staff actions were documented. However, the relevant person’s risk assessments and care plans were not consistently reviewed in response to incidents, as part of helping people to stay safe. For example, some people had experienced falls, but no review of their falls risk assessment or care plans had taken place, which meant they may be at increased risk of further falls. The provider had no effective system in place to help them identify possible themes and trends in accidents and incidents to ensure lessons were learned and minimise the risk of reoccurrence. People and relatives told us they could contact the service if they had any concerns about their care.

The provider did not 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.

The provider did not have appropriate and robust systems and processes to manage or monitor people’s safety through collaboration and joined-up working with partners in people’s care. They did not ensure there was continuity of care, including when people moved between different services. For example, one person had recently returned from hospital, but staff had not taken the necessary follow-up actions. They failed to contact the hospital for the discharge papers to checks for any changes in medication or the person’s care needs. There also was no evidence of any contact with the person’s GP for the missing information. Another person had returned from hospital with a discharge letter stating their blood pressure medicine should be stopped. However, staff had missed this instruction, and the person had continued receiving the medicine for 6 more days until the mistake was discovered. These incidents demonstrated staff did not consistently work in a joined-up way with partners to identify and act on important medical advice, which could have caused serious health issues. The provider lacked strong systems to monitor people's safety or manage updates from health professionals. There was poor continuity of care when people moved between different services, resulting in missed or delayed support.

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 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 carried out investigations into safeguarding concerns at the service; however, these investigations were not robust or effective. They failed to record sufficient information about the original safeguarding concern, and no details were maintained of the outcomes of investigations completed, actions taken to keep people safe or any learning identified and shared from these.

The provider did not always have systems and processes that supported them to identify safeguarding concerns. For example, 1 person’s care plan identified they were at risk of pressure sores There was further deterioration in the person's pressure injury. Staff did not have access to clear guidance or a defined process to follow. This meant that the person did not receive the care they needed in a timely manner. Red marks were observed by staff on 1 person’s lower arm, but these had not been documented, reported to management or investigated. When this was raised with a staff member, they demonstrated a lack of understanding about the need to complete a record, such as a body map, of the unexplained injuries or report these to management so they could be investigated.

There was a lack of oversight of safeguarding concerns by the provider. We raised concerns about the quality of their safeguarding investigations during the inspection. The provider was receptive to the feedback and agreed to implement new systems and processes to evidence more detailed investigations, actions taken and reflective learning. We identified potential safeguarding concerns involving 2 people which the provider’s own systems and processes had failed to recognise. We raised these with the local authority safeguarding team. The safeguarding team were satisfied with the subsequent actions taken by the provider to address individual concerns.

The provider had implemented an electronic care planning system; however, staff struggled to use it properly. They were unsure how to find important information, for example, records about people’s Deprivation of Liberty Safeguards (DoLS) authorisations. This lack of training resulted in poor oversight of care records and timely review and updates to support plans. In response, the provider has arranged further staff training on the electronic care planning system.

Relatives told us people were safe living in the home. One relative said, “I am very pleased with the care. When [my relative] had a fall, they called the paramedics right away.” Some staff told us they received safeguarding training, and they told us about the different types of abuse.

The provider did not always 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.

We found risk management plans were not in place that were linked to people’s needs such as mobility for using the stairs, skin and nutritional needs. For some people who were at risk of pressure related skin damage they had not been repositioned consistently. The records were not always clear to show if some people had been supported to reposition in line with assessed time intervals.

During the inspection, a person whose care plan and risk assessment clearly stated they should use a walking frame was observed walking independently and without supervision in the conservatory. Staff did not notice until inspectors intervened, indicating they may not understand risks to people.

These findings reflect a lack of consistent care delivery and poor risk management, placing people at unnecessary risk of harm.

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

During the inspection, several environmental and safety risks were identified which had not been picked up by the provider’s internal systems and procedures, revealing gaps in their oversight of the care environment. We observed unsecured blind cords in the conservatory, presenting entrapment and ligature risks. We observed a window without a restrictor fitted, increasing the risk of falls from this window. The provider took action to secure the blind cords and fit a window restrictor on the day of the inspection.

Inspectors also found a designated fire exit door, marked ‘do not lock’, had been locked and was therefore unusable in an emergency. This matter was only resolved following direct intervention from the inspection team. This indicated gaps in the provider’s understanding and implementation of fire safety responsibilities at the service.

In addition, no risk assessment had been completed in relation to variations in temperature within the service’s glass conservatory. The outdoor temperature recorded on the Met office website for the 21 May 2025 was 21°C degrees. Staff were observed complaining on how hot it was in the conservatory. Inspectors working in this area also experienced the heat. At the time, no thermometer or internal temperature monitoring system was present, nor were there any protocols in place to protect people from heat-related health risks. Whilst a thermometer was installed at the time of the sit visit no formal guidance to support staff on how to record and respond to excessive temperature to keep people safe had not been introduced.

Following a reported fall incident, staff had informed management that the Magna lifting cushion, a specialist device used to safely raise people who have fallen, was not working and that some staff were unfamiliar with its use. This piece of equipment was additional to 2 hoists available at the service. The battery had been ordered prior to the inspection; however, the provider had failed to follow up that this had not been delivered. The maintenance of care equipment and effective training for all relevant staff in its use is essential to maintain a safe care environment. When this was bought to the provider’s attention, a replacement battery was ordered for the lifting cushion by express delivery.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

Staff were not always recruited safely. A staff member employed at the service had been dismissed from a previous caring role. The provider had failed to follow up the reason for their dismissal, to determine if the staff member was suitable to work with vulnerable people and whether a risk assessment or additional supervision was required.

Not all staff members underwent a robust and comprehensive induction programme to prepare them adequately for their roles. For example, induction records indicated that some staff members’ induction had been completed in just 2 days. This short timeframe for induction raised concerns about whether staff were equipped with the necessary knowledge and skills required to deliver safe and effective care. Following the inspection, the provider introduced a new induction checklist designed to improve oversight and consistency in staff onboarding. This tool was intended to ensure future inductions were planned, audited, and properly documented.

The provider’s staff training audit had identified that a staff member had not completed all their mandatory training. The provider had instructed the staff member to complete 6 training modules during each shift. This was not practical, as no additional staff resource had been rostered, and did not demonstrate a commitment to effective staff training.

The provider had not assessed staff competency skills following training, meaning they could not be assured staff were using their training effectively. Staff we spoke with lacked understanding in critical some areas, including safeguarding and covert medication administration.

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 needed to develop a more robust approach to managing the risk of infection. Staff told us they were able to access the personal protective equipment (PPE) they needed to provide safe care to people. However, we found some practices to support good infection control could be improved. For example, posters on the walls were not laminated, some chair arms were worn. There were cleaning schedules in place to reduce the risk of spreading infection. However, we found that certain areas of the home had not been identified for cleaning. For example, we found dead insects on dusty window ledges in the conservatory, along with dirty skirting boards and a cupboard top containing porous surfaces, which would make it difficult to clean. The provider took steps to address some of these concerns by, for example, replacing furniture and applying new coverings to damaged surfaces.

Most staff had training in infection control practices and food hygiene. People using the service and their families said they felt safe in the environment. Feedback from relatives about cleanliness was mixed. One relative said, “The room is always clean, and the bed is made.” Another commented, “The place is a bit shabby, but they do their best. My [Loved one]'s room is always clean.”

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

The inspection identified concerns regarding the management of medicines within the service. The provider’s existing policies and practices did not meet current legislative requirements or established best practice standards, particularly in relation to the handling, recording, administration, and monitoring of controlled and prescribed medicines.

We identified incomplete records in the service’s Controlled Drugs register, which meant the provider could not be assured these medicines were safely managed. Controlled medicines require additional legal controls due to the risks associated with the storage and potential inappropriate use which could lead to significant harm or death. Senior staff also failed to escalate a known medicine administration recording error involving controlled medicine to the registered manager, indicating gaps in internal accountability and communication.

People were prescribed medication using transdermal patches, which are small adhesive patches placed on the skin. These patches gradually release medicine through the skin and into the bloodstream over time; however, no records were available to confirm the removal of previous patches prior to application of new ones. Additionally, application sites were not documented. Best practice requires rotating patch sites to reduce skin irritation and side effects, and the failure to record these details could result in unsafe medicine usage.

We found topical creams were not dated when opened, and there were creams with unreadable labels which were stored in a person’s bedroom in an unlocked cupboard. This is not in line with the best practice. Protocols for the use of ‘as required’ (PRN) medicines had not been reviewed. For example, some PRN protocols had not been reviewed since the relevant person moved into the service. The provider’s discarded medicines register was incomplete and did not include sufficient details of disposal and signatures confirming collection.

Medicines audits were not consistently completed. Where audits were available and presented to inspectors, they failed to identify several issues noted during the inspection. These included concerns around medicines storage, documentation, administration practices, and staff escalation procedures.

The provider was unable to demonstrate there were processes in place to effectively monitor medicines storage, ordering, recording and administering. We discussed the lack processes in place to effectively monitor medicines storage, ordering, recording and administering this with the provider, who following our inspection has introduced a revised medicines policy and procedure. The provider informed us a full review of systems and processes would be undertaken to improve the safe management of medicines across the service.