St James Court

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.

This is the first assessment for this service since a change of provider in October 2025.This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of a legal regulation in relation to governance at the service.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were provided with the vision and values of the company. Systems and processes were in place to communicate any changes in these to staff. The provider produced regular information bulletins for staff.
 

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. However, governance and oversight processes were not always effective in identifying and addressing all areas requiring improvement. Leaders had the skills, knowledge, experience to lead.The registered manager was not based at the extra care facility on a daily basis. Day-to-day oversight was provided by the on-site manager, who was in the process of registering with CQC as the registered manager.

The provider had been responsible for St James Court since October 2025. We noted the oversight and monitoring was not always effective in driving improvement. The registered manager, manager and provider had not identified the concerns we found.

Staff gave us mixed feedback about how they were supported by the management team. Two staff described the manager as “Approachable” and “supportive,” however, one member of staff told us they had concerns the management did not always listen or act on feedback to them.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Systems were in place for staff to speak up. Staff told us, "I understand concerns can be reported internally or externally, if necessary, without fear of victimisation” and "Staff should feel able to do this without worrying about being treated differently or facing consequences."
 

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We received mixed feedback from staff about how they felt valued. One member of staff told us, "In my experience, staff are treated fairly and with respect regardless of their background." However, another member of staff told us, "From my own experience, I would say no", in response to us asking if they felt fairly treated by the provider.

However, the provider operated equal opportunities for staff, systems were in place for all staff to be respected and valued. However, we found this was not the case in all staff who provided feedback. We have asked the provider to ensure all staff feel valued.

The provider had clear responsibilities, roles, systems of accountability. However, we found these were not always effective. We found the oversight and monitoring of the service had not identified the concerns we found.

The provider had conducted monitoring visits to St James Court. However, these were not effective. One visit carried out on 3 July 2026 stated, “Review of all care plans in light of recent safeguarding”. However, we found care plans had not been updated to reflect the current needs of people after this review.

The provider’s senior staff had visited St James Court in February 2026 following a fire, however, the provider’s visit record had not identified there were not any emollient risk assessments in place for the person who had experienced a fire.

The provider did not always ensure policies and procedures were followed. For example, a falls management policy was in place, which stated, a falls risk assessment should be in place and reviewed following a fall. We found this was not the case for one person. A falls risk assessment was put in place following our feedback to the provider on 16 July 2026.

The provider had a service development plan in place, however, this did not contain shortfalls which we identified. In addition, the plan had been created in 2025 and some identified dates for completion were end of August 2026. This placed an unnecessary delay in ensuring records were accurate and up to date. This meant there was an increased risk that actions identified were not addressed promptly to ensure people’s safe care and treatment.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider had worked closely with the landlord of the building and the local authority. The provider told us, some of the delays in action being taken was a result of waiting for information from the local authority.

People were encouraged to remain part of the local community.
 

Systems in place did not always drive improvement at St James Court. We found lessons learnt were cascaded to staff. However, the provider’s quality assurance systems were not used effectively to continuously improve the service. They had not consistently recognised gaps in risk assessments or contradictions in people’s medicines records.

The provider recognised the need for a change in their governance and monitoring. The registered manager told us, “At present this is combined with [another service] but we are now going to be splitting them and St James Court will follow the extra care audit calendar and monthly governance report.”