Archived: St. Catherines Residential Care 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 our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Inadequate.

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of legal regulation in relation to their lack of effective governance, quality assurance processes and oversight of the service.

This service scored 46 (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 clear shared vision, strategy and culture. The staff we spoke with were unable to tell us about what the provider’s overall vision for the service or values were.

Although the provider had some systems in place to encourage the involvement of, and feedback from, people, their relatives and staff, such as residents’ meetings, staff meetings and feedback surveys, it was not clear how feedback on the service had been used to drive improvement. This represented a missed opportunity to more fully staff in the vision, values and strategy for the service. The provider’s failure to demonstrate how feedback on the service was consistently used did not reflect a listening culture, focused on learning and improvement.

Staff had received equality and diversity training; we saw gentle and kind interactions between staff and the people they were supporting. We saw no evidence of any form of workforce inequality.

The management team failed to convey a clear strategy for the service and did not have any robust action plan in place to address any challenges or shortfalls in quality and safety.

The provider and management team did not convey a clear sense of the culture and values of the organisation. The provider had not ensured the registered manager was provided with formal supervision and appraisal, as part of ensuring they had the skills, knowledge, experience to lead effectively.

We identified an absence of formal supervision or appraisal for the registered manager, who had been in post for 4 years. This represented a missed opportunity to assess leadership performance, identify support needs, and encourage professional development.

We received positive feedback from people using the service and their relatives who knew the management team and found them approachable and visible in the service. One relative shared that the registered manager was responsive and made time for conversations when approached.

Routine safety checks were carried out by the registered manager, but some environmental hazards had not been considered or addressed. Unaddressed environmental risks to people included a locked fire exit, unsecured blind cords, and a lack of temperature monitoring in the conservatory during extreme weather. However, once concerns were raised, the manager and provider both took immediate action to rectify the issues.

The registered manager told us they had an open-door policy to allow people, relatives, staff, and professionals to raise concerns or any feedback. Most staff we spoke with told us they felt comfortable approaching and the provider and management team with issues and concerns about people’s care and had confidence these would be listened to and addressed. However, where feedback on the service or people’s care had been provided by another means, such as comments made during team meetings or on feedback surveys, it was not clear what action had been taken by the provider and management team in response to this. For example, staff surveys had been distributed in the last quarter, but only 10 responses were received, and no analysis had been completed at the time of the inspection. Retrospective analysis was later carried out, with action points identified, but these had yet to be implemented.

The provider had a whistleblowing policy and complaints management system in place, and staff were informed of this as part of their induction.

Surveys and questionnaires were distributed to people living at the home, their families and friends, to invite their feedback on the service. However, responses had not been formally reviewed or analysed for any concerns. Some relatives told us they were unaware of the feedback process, as no information had been shared with them. One relative told us they could raise concerns if they arose. Another relative told us, “I am regularly asked if everything is ok and if anything is not working.”

Following the inspection the provider informed us they would be issuing regular staff, family and service users’ questionnaires and ensuring prompt analysis to support learning for improvements across the service.

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.

Policies were in place to promote equality, and the organisation had recruited a diverse staff team, including people with additional support needs. Staff received equality and diversity training, and some staff shared that their requests for flexible working patterns had been accommodated.

Staff also confirmed they had opportunities to participate in team meetings, which allowed them to express concerns and contribute to service delivery discussions. However, upon reviewing staff meeting minutes, it was noted there was a lack of evidence of the provider’s response to some concerns raised by staff, such as delayed recording of care delivered using handheld devices and the continued use of personal phones during work hours.

The provider had recruited staff with learning difficulties or developmental disabilities, including dyslexia and autism. However no formal recorded assessments of any additional support or adjustments these staff needed had been conducted at the time of inspection. Following our feedback, management took immediate action to implement appropriate assessments, with a commitment to reviewing them annually or as needed.

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. Improvements were needed to ensure records were fully completed and care plans and daily notes fully reflected the support people needed and received.

The provider did not have effective and robust governance systems in place to monitor the quality and the running of the service. For example, the provider’s quality assurance systems and processes had not enabled them to identify that people’s care plans and risk assessments did not always include relevant, up to date guidance for staff. Care plans were reviewed but these were not always updated to include current and relevant information. People’s daily care notes and records were not always sufficiently clear or detailed and did not always identify what actions were taken when concerns were identified. For example, records of what food had been eaten, and portion sizes were not always detailed enough to enable staff to monitor trends and help detect early signs of malnutrition or dehydration, or to provide reliable data for consultation with dieticians or healthcare professionals. Again, the provider’s auditing systems had not enabled them to identify and address these concerns.

Some care staff had been allocated medicines audits and checks which they completed, but they had not received the appropriate training to support them with the completion of audits. Following a medication audit in March 2025 actions had been identified but there was no action plan to say these actions had been completed. For example, the audit had identified some concerns regarding medicines signed for but not administered, missing medicines or incorrect tallies of remaining stock. However, there was no evidence of any actions being taken to mitigate the risk of reoccurrence. The medicines audits completed did not demonstrate how they were being used to improve the service.

We found audits completed at the service had failed to identify and address the shortfalls we found at this inspection, including risks within the care environment. Following the inspection the registered manager told us about changes they were implementing to audits to start to make the improvements at the service. However, time was needed to ensure they became fully embedded into everyday practice.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not share information and learning with partners and collaborate for improvement.

Where staff and management had received advice or recommendations from healthcare professionals regarding people’s care, there was a lack of evidence how these were consistently implemented. This included advice from the district nursing team. Where people had recently been discharged from hospital, discharge paperwork had not been consistently requested or the instructions on this consistently followed. This did not promote joined-up care.

The provider and registered manager had not engaged in local or national forums or development groups. This meant there had been missed opportunities for learning to improve people’s experience of care.

The management team were not working closely with the local authority quality teams to improve safety and quality in the service and keep themselves up to date with any offers of training or updates within the care market. The lack of close partnership collaboration limited the provider’s opportunities to make improvements and strengthen care quality.

The provider did not always focus on continuous learning, innovation and improvement across the organisation. 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 were some systems and processes for assessing and monitoring the safety and quality of people’s care. However, these had failed at identifying and driving improvements at the service. This meant the quality and safety of people’s care had been compromised, in some cases, including the safe management of people’s medicines and the effective monitoring of their fluid intake.

We found concerns relating to the provision of care delivery. We were not assured that people’s risks were competently assessed and monitored, and that learning from previous incidents was effectively and safely managed. We did not see evidence of a robust system in place to ensure the effective review of safety concerns, incidents and safeguarding matters. We were not assured that all incidents had been addressed appropriately for continuous improvement and learning shared across the service. This placed people at the risk of harm, and people were at risk of not consistently receiving safe, good quality and effective care.

The registered manager carried out audits of the service. However, these audits failed to identify the concerns we identified during our inspection to ensure the safety of people and staff. The provider lacked effective systems to monitor and mitigate risks and to learn lessons to mitigate the risk of incidents happening again. The provider did not conduct any analysis of accidents and incidents to allow lessons to be learnt to help keep people safe from further injuries.

Although the provider had systems and processes in place designed to capture people and staff’s feedback on the service, this feedback was not consistently and effectively used to drive improvements.