St Clare's 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 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 regulation in relation to the ways people’s medicines were managed safely.

The provider was previously in breach of the legal regulation in relation to staffing. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had an open learning culture. Staff reported incidents and said safety huddles were used to share learning and agree actions. Relatives told us they were kept informed when things went wrong and felt confident the service acted transparently. Records showed incidents and environmental checks were reviewed so trends could be identified and improvements made. Staff said they could raise concerns and would be listened to. This supported a culture where learning was embedded and people were protected from avoidable harm.

People experienced safe and consistent care because staff followed clear processes for assessment, handover and communication. Staff knew people well and shared information effectively so day‑to‑day care was coordinated and responsive. Relatives told us staff contacted them promptly when someone became unwell and worked with health professionals to make safe decisions. Care records showed timely referrals and clear actions taken in response to external advice. These arrangements supported safe pathways and helped ensure people received coordinated care that met their needs.

People were protected from abuse and neglect because staff understood their safeguarding responsibilities and knew how to report concerns. Staff had current safeguarding and MCA training and were confident describing what they would look for and who they would inform. People and relatives told us they felt safe in the home. One person said, “I feel quite safe here,” and another said, “I feel safer here than I did at home.” A relative told us they were reassured, saying, “I’m happy that my [family member] is in a safe place where they understand their needs.”

The service made appropriate safeguarding referrals and shared information with external agencies when needed. Applications for Deprivation of Liberty Safeguards were submitted when required and staff understood the restrictions in place for people.

People were supported to understand risks and were involved as much as possible in decisions about their safety. Staff knew people well and used this knowledge to identify early changes or concerns. Relatives told us they were kept informed when risks increased and felt staff acted quickly to keep people safe.

Staff took steps to protect people from risks linked to wandering and unwanted entry to bedrooms and relatives told us action was taken when concerns were raised. These arrangements supported a safe environment and helped protect people from harm.

Staff understood how to respond to behaviour or distress in a calm and consistent way and used proportionate approaches that balanced safety with people’s independence. Staff described how they monitored known risks and worked with external professionals when additional support was needed.

People lived in an environment that was clean, well maintained and suitable for their needs. Routine checks of equipment, fire safety systems and water temperatures were completed and any issues were dealt with promptly. Staff knew how to report environmental concerns and told us action was taken when they raised something. People and relatives said the home was kept in good condition and felt safe using the communal spaces. Systems for maintenance and monitoring helped ensure the environment remained safe for people and staff.

The home had enough staff to meet people’s planned care needs and rotas showed staffing levels were consistent with what the provider had assessed as required. This meant they were no longer in breach of regulation. People and relatives told us staff were available when needed. However, staff feedback was mixed about staffing levels. Some staff told us there were enough of them to meet essential needs, while others said they would have liked more time to spend with people. One person reflected this, saying, “There does seem to be a lack of staff at times and they don’t have enough time to spend with me.”

During the visit we saw staff present in communal areas and responding when people asked for help. Interactions were calm and respectful. The activities coordinator spent focused time with people, leading group activities and offering one‑to‑one engagement, which supported meaningful contact even during busier periods.

Recruitment processes were in place, including required background checks. However, the provider had not ensured gaps in employment history had been explained before staff started work. This created a risk that suitability checks were not fully completed. After this was highlighted during the inspection the provider began reviewing staff files and requested the missing information, which reduced the risk going forward.

A structured training schedule was in place and staff had access to relevant courses. However, training needed for specific roles had not always been prioritised. For example, food safety training for a kitchen assistant had not been completed. This meant some staff were working without the training they required for safe practice, increasing the risk of inconsistent standards. The provider began addressing these gaps once they were highlighted.

The home was clean and hygienic and people told us they were satisfied with the standards throughout the building. Staff followed safe infection prevention and control practices and we observed consistent hand hygiene and the use of Personal Protective Equipment (PPE) when required. Communal areas, bedrooms and bathrooms were visibly clean and we saw domestic staff completing regular cleaning tasks during the visit.

Laundry processes were organised and linen was handled in line with safe practice. People said staff supported them with personal hygiene when needed. Staff understood what to do if they were concerned about infection risks and told us they would escalate symptoms promptly. Relatives said they were informed when their family member was unwell and felt confident the home acted appropriately.

Systems were in place to monitor cleanliness, check equipment and identify any concerns that required attention. These arrangements helped protect people from the risk of infection.

Medicines were not always stored safely or securely and this created avoidable risks. Temperature monitoring for storage areas did not provide assurance medicines were kept within manufacturers’ recommended ranges. During inspection, temperatures exceeded the maximum safe range, and some medicines may no longer have been suitable for use. Expired medicines were also found in storage areas. This meant there was a risk that people received medicines that were unsafe or no longer effective.

Care plans contained information about some long‑term conditions, but medicine related risks were not always clearly assessed, for example bleeding risks linked to medicines that thin the blood. Medicines information in care plans was not always up to date. When a person had been admitted to the home, the information about their medicines did not explain what had changed or any risks that applied to them.

Some people had been refusing some medicines for several weeks without appropriate follow up, including medicines used to counteract side effects of high‑risk medicines. Care plans did not contain enough information on how to manage these risks. Administration charts for creams and patches could not be located, meaning staff did not have the information needed to apply these medicines correctly. Protocols for medicines taken when required (PRN) were missing for some people and not consistently followed for others.

Although medicines administration records (MAR) showed regular administration of most medicines, record keeping for PRN medicines was inconsistent, so it was unclear whether these medicines were routinely offered.

The home had positive working relationships with external professionals and critical medicines protocols were detailed for some high‑risk medicines. Staff competency records were in place, although evidence for one staff member administering medicines during the inspection could not be provided.