St Clare's 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 good. At this assessment the rating has changed to 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 legal regulation because governance systems were not effective in identifying or addressing the shortfalls found during the inspection.

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.

Staff described the culture as open and supportive and said the registered manager was approachable and available. Staff were clear about their roles and worked together in a consistent way. The registered manager promoted open communication and staff said they felt able to raise issues and contribute ideas. These arrangements helped maintain a stable culture and ensured staff understood the values and expectations of the service.

The registered manager was visible in the home and spent time speaking with people and staff, which helped maintain an approachable and friendly atmosphere. Staff told us they could go to the registered manager if they needed advice or wanted to raise something.

The registered manager had oversight of the day‑to‑day running of the service and responded when issues were highlighted. Staff described positive working relationships and said communication within the team was open and supportive.

The registered manager had begun addressing areas identified during the inspection, including improving documentation and oversight. These arrangements showed leadership that was accessible and willing to act when concerns were raised.

Staff said they felt able to raise concerns and told us they were comfortable speaking with the registered manager if they had something they needed to report or discuss. Staff described an open atmosphere where issues could be brought forward without worry and said they were listened to when they raised suggestions or highlighted areas that needed attention.

We saw staff communicate openly with each other and share information throughout the day, which supported a culture where concerns could be discussed as part of normal practice. Staff said they would report anything they were unsure about and felt confident the registered manager would take it seriously.

Policies and processes were in place to guide staff on how to raise concerns and staff knew where to go if they needed to escalate something. These arrangements helped promote a culture where speaking up was encouraged and supported.

Staff were treated fairly and supported in ways that recognised their individual needs. Leaders made reasonable adjustments where required, including adapting duties and working patterns to help staff remain in work. Staff told us they were comfortable discussing any support they needed and said the atmosphere in the home was inclusive.

We saw examples of staff being given flexibility to accommodate health needs or personal circumstances, and staff said these adjustments made it easier for them to carry out their roles. Policies were in place to promote equality and inclusion and staff said they felt able to raise concerns or ask for support without worry. These arrangements showed the home promoted a fair and supportive working environment where staff were treated as individuals.

Governance systems were in place but were not consistently effective. Medicines audits had identified some issues; however not all concerns were picked up and actions recorded were not completed in a timely way. This meant audits did not always lead to prompt improvements. Audits had not identified expired medicines, unsafe storage temperatures or missing records for creams, patches and medicines taken when required. As a result, key risks linked to medicines management had not been recognised or acted on through routine checks.

Other concerns raised during the inspection, including incomplete recruitment checks and aspects of consent and care planning, had not been identified through the provider’s own systems. Oversight was present but had not been effective in highlighting when records needed updating or when documentation did not fully reflect people’s needs. Although the registered manager responded when issues were raised, the governance arrangements had not identified these matters independently. These shortfalls showed that the systems in place to monitor quality and safety were not reliably detecting issues or supporting sustained improvement.

The home worked cooperatively with external professionals and sought advice when people’s needs changed. Care records and daily notes showed staff contacted community health teams, GPs and other professionals when support or guidance was required. Staff described positive working relationships with visiting services, which helped ensure people received input from the right agencies at the right time.

The registered manager engaged with the local authority and safeguarding partners when needed and responded to information requests from external bodies. Documentation reviewed during the inspection showed the home shared updates when asked and provided information to support joint working.

People continued to take part in community activities when this was important to them. Staff supported people to attend appointments or outings and the home maintained links with local services such as the church.

The home took on board feedback and made changes when issues were identified. During the inspection the registered manager began addressing shortfalls in documentation and recruitment files and took steps to improve oversight where gaps had been found. Staff said they were encouraged to raise suggestions and felt able to discuss ideas for improving day‑to‑day practice.

Learning from incidents and feedback was shared informally, and staff spoke about how they discussed issues during handovers or when concerns arose. The home used advice from external professionals to adjust care when needed, which helped support safe practice.

Innovation was limited, but improvements were made when required and leaders were open to reviewing systems when concerns were highlighted. These arrangements supported ongoing learning and helped the service make steady improvements over time.