Saint Jude 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 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.

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. Lessons were not always learnt to continually identify and embed good practice. For example, whilst there was a system in place to record and monitor accidents and incidents there was limited evidence to demonstrate how this information was analysed or used to drive learning and improvement. Management sign‑off on accident forms was not always completed, and the language used in some reports focused on individual fault or behaviour rather than exploring underlying causes or identifying proactive solutions to support people safely.

However, staff understood how to report safety incidents, and family members told us they were informed when incidents involving their relatives occurred.
 

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. For example, a family member told us they were happy about their relatives’ transition into Saint Jude’s; they were given time to look around and helped to collate information to inform care plans. Staff told us when someone new moves in, they can find out what their support needs were by reading care plans. Information was shared with staff at handover meetings. Management and staff knew how to contact health and social care services when they were needed for people to manage health conditions.

The provider did not always ensure safeguarding practices were consistently embedded across the service. For example, although refresher training was available, staff did not consistently complete it, with significant numbers overdue in key areas. Management had highlighted these gaps but had not taken effective action to improve compliance. This shortfall sits within wider governance concerns.
However, staff told us they felt confident raising issues if needed and understood the whistleblowing process. Family members told us they felt able to speak with the registered manager if they had any concerns. Mental capacity assessments were completed where required, and applications for Deprivation of Liberty Safeguards (DoLS) authorisations were submitted and approved appropriately. The provider notified the local authority of safeguarding concerns in a timely manner.
 

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. For example, risks to people were assessed and documented within care plans, but these were not always clear or easy for staff to follow. Some risk management plans contained large amounts of information, which made it difficult to identify the key risks and how staff should support the person safely. Additionally, some information was conflicting or outdated due to irregular and incomplete reviews. One person’s care plan listed they should take both 1 and 2 daily nutritional drinks, which could lead to inconsistent support. Staff knew people well but felt the quality and accuracy of written records did not always help them provide care consistently. The registered manager had an action plan to address the inconsistencies but had not yet managed to complete this.
Involvement in care planning was not consistently recorded for most people. However, one person we spoke with told us they were involved in and contributed to their own care plan.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. For example, the provider employed a maintenance person who completed regular checks on fire safety equipment, emergency lighting, fire doors and fire drills. An external company completed gas safety checks. Electrical safety testing was completed in line with best practice, additionally the home benefitted from a lift, which had a regular service schedule.
Equipment used to support people with mobility needs was clean, regularly serviced and available when required.
We observed damaged flooring in the bathroom, which posed a potential trip hazard. However, the provider informed us this bathroom was scheduled for renovation at the end of the month.
 

The provider did not always make sure staff had the right skills, learning and experience. They did not always make sure staff received effective support and development. For example, staff had raised concerns in a team meeting in both May and June 2025 they required additional training on the care planning system, but this had not yet been completed due to staffing pressures; the registered manager informed us staff development was an ongoing priority.

The training matrix did not clearly show when staff had completed training courses and when they were due for a refresher. This limited effective oversight and contributed to low compliance across key subjects. The lack of an effective system to track and improve training completion reflected broader weaknesses in governance.

One family member commented, “There seemed to be a large staff turnover, but there is some continuity of staff.”

However, staff were recruited safely. The provider ensured all required pre‑employment checks were completed before staff started work. When agency staff were used to cover shifts, the registered manager obtained profiles to confirm they were suitably trained and had the necessary skills. They ensured a same agency workers were used to support continuity of care.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. For example, there were several areas where standards of cleanliness and infection control required improvement. There were no cleaning schedules in place throughout the home, meaning there was no structured or auditable system for maintaining hygiene standards. Although most rooms appeared clean and tidy, we observed dust and an overflowing bin in two bedrooms.
The kitchen environment was unclean. We found discarded food underneath cabinets, and kitchen equipment and drawers contained visible food residues and debris. Out of date food was present in both the fridge and dry food storage areas. The registered manager explained the cook had recently left abruptly and had taken the cleaning rota with them. Despite knowing this, the registered manager did not put a replacement in place and the extent of uncleanliness observed suggested the issues were longstanding. When feeding back these concerns, the registered manager gave assurances they would be addressed without delay. The provider had recruited into the vacant cook position, and they were due to start shortly after our visit.
Some areas of the home had chipped paintwork, which can hinder effective cleaning and is not in line with good IPC practice. The extent of the issues indicated an absence of effective managerial oversight of IPC.
However, staff were provided with adequate PPE, IPC e learning was available, and the majority of staff were compliant with this training.
 

The provider did not always ensure medicines and treatments were managed safely or in a way that met people’s needs, capacities and preferences. For example, medicines administration records (MARs) were not always complete, and sample signatures were missing, making it unclear who had administered certain medicines. The quality of people’s profile sheets varied; some contained full information, while others lacked essential details. Handwritten MAR entries frequently had no counter signature, and no body maps were in place for topical creams or rotational patches, meaning staff did not have clear guidance on application sites. There was no evidence medicine room temperatures were being monitored, despite a thermometer being available. This meant the provider could not be assured medicines were consistently stored within safe temperature ranges.

Medication risk assessments and supporting documentation did not always provide staff with sufficient information. For example, a diabetes risk assessment lacked detail regarding signs of hypo or hyperglycaemia, limiting staff’s ability to recognise and respond to changes in a person’s condition. There were inconsistencies in ‘as required’ (PRN) protocols. Some PRN protocols were missing, some lacked detail, and others existed for medicines not recorded on the MAR, creating a risk of medicines being used without appropriate guidance or oversight. The registered manager acknowledged PRN protocols required improvement and stated this work was on their improvement plan.
There was no evidence of recent medicines audits, despite the registered manager reporting they had been completed. Blood pressure monitoring charts showed missing twice daily readings across several days, meaning staff were unable to demonstrate effective oversight of a known health risk.
However, people generally received their medicines safely and on time. Staff understood when medicines needed to be taken with or before/after food, and we observed effective handover arrangements to support the administration of time critical medicines. Medicines were stored securely and were within expiry date. When people were assessed to lack capacity around their medication and it was concealed within food or drink, this was managed appropriately, with correct authorisation from the GP.