St Luke'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.

This service scored 59 (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. Staff were reporting and recording safety events; however, these were not always followed up to continually learn, identify and embed good practice. For example, an accident form had been completed by a staff member relating to a person having a fall, but their care plan and risk assessments had not been updated in relation to this accident to mitigate future risk.

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. The provider carried out pre-admission assessments before people moved to the service. People were happy with the transition to the home. One person told us “Yes me, and other family members had a meeting about [relatives] care needs before they moved in”. The manager told us she had recently met with the commissioning team at the local authority to discuss admissions and safe transitions into the home.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. During our assessment we found that safeguarding events were logged, referred, investigated, and responded to. The provider had oversight and analysed safeguarding events with lessons learnt reviews. The required statutory notifications were submitted.

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. We received mixed feedback from people when we asked if they were involved in planning their care. Some people and relatives felt they were involved in their care plan, risk assessments and reviewing process, but others did not recall being involved. One person told us “No I haven’t seen [relatives] care plan”.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. For example, we found equipment for safe moving and handling was stored in a corridor, in front of a fire exit. This was a risk to people in case of an emergency and posed a risk to people falling over the equipment. The provider did move this equipment to a more suitable place during our assessment. Other fire safety measures were in place. Staff told us they had received fire training, and we found evidence of regular fire drills. All other required maintenance checks were in place and up to date

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. Staff, people and relatives told us they did not feel there were enough staff on duty to meet people’s needs. Relatives told us “No, I don’t think it is safe, there are lots of falls and when the residents are in the lounge there are no staff in there watching people” and “I don’t think there are enough staff on duty which we have all mentioned in meetings but things have not changed with staffing levels, people we care for all have high dependency needs”. The provider used a high level of agency staff. We received mixed feedback from staff in relation to regular, supportive supervision; however, staff told us they felt they had enough training to do their role. Staff files we reviewed showed that staff were recruited safely with mandatory checks completed.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. There was an infection prevention control (IPC) policy and effective processes in place. The manager was clear on the IPC procedures required and their responsibility to provide personal protective equipment (PPE). During our assessment no concerns were identified with IPC, all areas of the home were clean, and staff wore and disposed of PPE correctly. IPC audits were carried out and people did not raise any concerns in relation to IPC.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. We looked at medicine related records for 3 people. Medicines administered covertly did not have all the required documentation to support this, such as, instructions from a GP or other healthcare professional confirming how individual medicines could be administered covertly and safely. Prescribed creams were not always signed for. One person’s pain patch was prescribed to be applied once per week but was signed for as applied on the 29 and 30 August 2025. People’s morning medications were sometimes administered late morning or at lunch time. This also meant people’s subsequent medications continued to be administered later throughout the day to ensure sufficient gaps. Not all staff knew where ‘when required’ (PRN) protocols were stored. We also looked at how medicines were stored, including creams and controlled drugs. Medicines were stored appropriately and organised securely in cupboards and drug trolleys which were kept in treatment rooms. Temperature monitoring of the treatment rooms and fridges where medicines were stocked was recorded daily throughout the home. People did not raise any concerns in relation to their medicines. We did not find impact to people.