St Catherines 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

People living at St Catherines were not always protected from abuse. Provider oversight, knowledge and the reporting of safeguarding incidents was ineffective. Safeguarding incidents and concerns had gone unreported with actions taken that did not enable a full and transparent investigation into such incidents. While people felt safe; some relatives agreed while others felt that their family members were at risk at harm and recommendations from safeguarding investigations had not been implemented.

Medicines management was not safe with the result that many people had not received prescribed medicines which placed them at risk. Stocks of medicines were not ordered in a timely manner and there was no effective oversight to remedy repeated omissions over several months.

Staffing levels were not sufficient to meet the needs of people. Staff were not able to effectively supervise people given the high dependency needs of people and as a result their work had become task orientated with little time to interact with people in a meaningful way. People had unwitnessed falls which suggested that staff resources were not sufficient to supervise them and keep them safe.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they felt safe. Relatives gave mixed views of the safety of their relations within the service. While some were assured, others had identified when concerns were raised; they did not receive feedback whether these had been investigated, or appropriate action taken. One relative had raised a safeguarding concern with the local authority. Recommendations came from this investigation yet the relative did not see any progress in addressing or remedying these.

Staff told us they knew how to record any accidents or incidents and then pass it for management review. They told us there was no debriefing sessions or reflection about falls to prevent future re-occurrence. Staff were concerned staffing levels had an impact of the safety of people. The provider did not provide sufficient evidence lessons had been learned from all adverse incidents. This meant people would continue to be at risk of harm.

While accidents and incidents were recorded, the provider did not have an effective system for the reviewing of events such as unexplained bruising, skin tears or unwitnessed falls. Some people had experienced many unwitnessed falls which had been recorded yet there was no analysis of how these could be prevented in the future.

In respect of unexplained bruising, some incident records had attributed these to techniques with lifting and handling of people relying on portable hoists. There was no evidence this had been followed up with refresher training and training records in manual handling competency were at 54% of staff.

No reflective processes were in place for staff after any incidents had occurred to learn lessons. As a result, people remained at risk of harm.

People and their families had no comments to make in respect of continuity between services.

Staff did not comment on continuity between services.

Partners were concerned information from the service was not always forthcoming, with important safeguarding information not always been reported. No care concerns had been reported to the local authority from the service from January to September 2024.

There was no evidence of care plans being devised in partnership with people and their families. A digital platform was used to maintain and store records, yet they were not accessible to people. Care plans were reviewed; however, these were done in isolation by clinical staff and there was limited evidence there had been other professional input into reviews

People felt safe living at St Catherines. Relatives provided mixed views. Some considered their relations were safe, “Yes I have no concerns” and “Yes they are safe”. Other relatives did not consider their relation to be safe.

One person commented, “Most of the time [name] is not safe. I raised a concern regarding a burn on their finger, there was no accountability, no one had noticed it, and it had not been documented”. They further commented they had not been informed when their relative had not received painkillers for a number of consecutive days. When they were informed, they were told it would be reported to safeguarding. There was no evidence this had been done. Another stated, “No [name] is not safe” and “I had arranged a safeguarding meeting, and no one turned up”.

There was no evidence these latter actions had been done, and this was confirmed by the relative during the assessment process. Concerns about the person’s accommodation were also included in recommendations with regular checks to be monitored through manager audits. There was no record of these checks being completed

Relatives commented they had found their relatives on occasions in an unkempt state or needed support with their continence needs.

As a result, the provider failed to ensure safeguarding actions were undertaken to safeguard people.

Staff confirmed they had received safeguarding training, and they were able to report events through incident forms and were aware of the safeguarding procedure.

A whistleblowing process was in place; however, whistleblowing processes were not known by all staff and many concerns were generated and received by CQC following the first day of our visit. One member of staff said, “[The whistleblowing procedure] is not something I've been shown or told about before” This meant not all staff knew what the whistleblowing procedure was or feel comfortable in approaching the registered provider at senior levels to raise concerns.

Staff told us they were concerned staffing levels put people at risk of harm.

We undertook a Short Observational Framework for Inspection (SOFI). This is a tool for is directly observing and reporting on the quality of care experienced by people who may not be able to describe this themselves.

For the most part of our observations, no staff were available to check on the wellbeing of three people located in a lounge area apart from a 30 second intervention. During this time, one person was looking to leave their wheelchair which may have led them to fall and was at one point crying out in distress. Another person was also in distress, but staff intervention enabled them to be reassured.

We observed and attended a safety meeting on the first day of the inspection. This provided a discussion of clinical issues had arisen for people. The meeting involved a Quality Director who was present on the first day of our visit and the Clinical Lead. The meeting was detailed and thorough. However, proposed actions of referral to the safeguarding authority as care concerns or notifications to CQC were not always completed.

The process of reviewing incidents was not robust as incidents required reporting to the safeguarding authorities had not been done. For example, one person experienced a skin tear and unexplained bruising. The staff on duty had recorded, “[Name] has also sustained new bruises and skin tears weren't there yesterday evening when we left the shift.” They further recorded, “there was blood all spattered up the wall at the bottom by [their] feet had dried, looks like it had come from toes on right foot”. An incident form was completed but the subsequent managerial review only suggested relatives should be informed. There was no evidence this had been reported to ensure external input oversight and transparency.

Another person sustained injury to their left shin recorded as an unknown injury. No safeguarding referral was sent to the safeguarding authority and as a result, the provider had failed to keep people safe.

Relatives told us they felt their relations were safe. Some did not. They cited general support provided as leading to this conclusion as opposed to individual risk assessments

Staff told us they were able to access risk assessments.

No observations in relation to risk were made.

Hazards faced by people from individual health needs and the wider environment were in place. There was no evidence risks had been devised in partnership with people and their families. Risks for people at risk of malnutrition were in place and action taken to reflect weight loss. This did not apply to all people as one person had been assessed as being normal weight and then eventually underweight. No evidence of action taken was available to deal with this.

Fall risk assessments were in place, despite these, people experienced many unwitnessed falls, and no evidence of risk assessment review could be seen.

Some family members had no concerns about the environment while others commented outside areas (the rear garden) were neglected and “unsafe”. They commented the appearance of the home to the front was “full of rubbish and cigarette ends”.

The manager provided evidence equipment in the building was regularly checked and safely maintained. Maintenance staff were employed and attended to those repairs did not require any specialist input. Staff commented a staff room was not in a good state of decoration. We visited this room and found this to be the case although the manager assured this was to be redecorated in due course.



We identified some parts of the building needed some redecoration and refurbishment. The Quality Director present on the first day of our visit had ordered new armchairs and furniture. This had been welcomed by staff who commented positively on this. The Quality Director also stated it was their intention to seek refurbishment of both living area and was planning some work on how this could be achieved without disruption to people. The quality director had then been allocated to another service, so it was unclear if this wholesale refurbishment was going ahead. Staff told us, “I felt better last week because the director said there was money for things [which were] ordered. They have left now”.

The rear garden was not well maintained. No one was observed accessing this area during our visit either independently or with staff support. Facilities such as call alarms were available, however, we saw staff responses were not always prompt.

Documentation was in place to confirm regular servicing of facilities within the building as well as equipment used.

People told us staff were not always available to respond to their needs. People cited examples when they had asked for help and had been promised this, but staff never returned to assist them. Family members were concerned about the lack of nursing staff especially at night and two provided an example where their relative had been in pain and was not able to be assisted due to the nurse having other people to attend to. One relative told us they felt their relation was at risk of isolation and neglect. All concerns were attributed to staffing levels did not meet the needs of people or keep them safe.

Staff had mixed views about staffing levels. Some believed there were enough staff, but others were concerned about a recent reduction in staffing levels. They said, “staffing is an issue, if we are short staffed bath/showers can often get missed until the next day.”, “Some days it [staffing] can be improved. Sometimes there are 3 on the floor and other days we have 4”,” We have been begging for more staff” and “Lots of residents are still in bed at 11.30am-12pm with curtains closed. Staff advised they do not have time to get everyone up”

Our observations found staff were not always available to check on the welfare of people. Some people who required assistance and appeared distressed did not receive timely support.

People did not receive adequate support with eating. There was a significant delay in one person being offered support to eat their main meal. After this support was provided, they struggled to eat their dessert and still assistance did not come in a timely manner.

Staff had little opportunity to interact with people other than when supporting them with personal care.

Call alarms were activated on many occasions during our visits. The response times for these were not always prompt with one example being more than five minutes. Some staff appeared to ignore call alarms and walk past the room where they had been activated.

Staff dependency tools were in use, yet these were outdated and referred to a model used in another part of the United Kingdom which was not subject to the same quality standards as used by the Care Quality Commission. The dependency tools were not clear and did not take environmental factors, required clinical input or the views of people and their families into account. Recruitment of staff was satisfactory.

People told us the building was kept clean and tidy and did not have concerns in respect of cleanliness.

Relatives had mixed views of hygiene standards in the building. One relative told us, “[The] bin not being emptied, the bedroom floor is sticky, and the table was dirty” [in Name’s bedroom]. Another said, “The home is not clean. I saw broken plates under bed and food stains on [names] bedding.”

Staff commented on the hygiene standards in the building. These included, “We've been begging for more staff for months and begging for cleaners because the home is dirty everywhere nothing has happened”, “Our staff room is disgusting filthy dirty mouldy chairs and broken table and fridge” and “No it’s OK”.

We did not observe any concerns with infection standards within the building during our visits.

Two people had infectious conditions needed to be managed to prevent their spread. Processes and information were in place for staff to refer to and there were sufficient stocks of personal protective equipment in place to ensure infection did not spread.

An infection and prevention control visit was undertaken and a report provided to us. A visit in September 2024 had identified concerns around cleaning provision, cleaning processes and was related infection prevention and control measures. An action plan was devised and at the time of this report, this was being worked through by the service. One issue had been the need for staff training, and this was in the process of being provided.

One relative had reported to the service and to us their relative had not received painkillers as prescribed for a number of days. This was confirmed by medication records and care notes. The relative was concerned they had not been informed of this straightaway and they were informed it would be reported to safeguarding. We found no evidence this had been done. The relative stated, “I don't get any feedback as a result of anything raised” Another relative told us "I requested them to phone me if there were ever any issues, for example, with not taking medication. I went in and they tell me [name] hasn't had medication for 3 days. They don’t do as I ask”.

The manager provided evidence the medication systems had been assessed by the independent Medicines optimisation in care homes team (known as MOCH). This had concluded medicines management was safe. The MOCH audit had, however, not included issues of non-administration of medication or when required medication (PRN) protocols in its scope. Medication storage was safe, and controlled drugs were secure and accounted for. Medication trolleys were locked in between times of administration. Medication was observed as being administered safely. Only registered nurses administered medicines. Nurses were all currently registered on the Nursing and Midwifery Council register with competency checks carried out. We saw evidence nurses responsible for the administration of medicines had had their competency checked annually.

Medication records evidenced medicines management was not safe, and people were at risk of significant harm. Records indicated there had been more than 500 occasions over approximately three months in 2024 when medication had not been given. Reasons for this included, “not being available”, “not in stock” or not “unable to locate”. Managerial audits recorded remedial actions which were inconsistent and referred one occasions to “nursing staff to ensure stocks of medicines are ordered in a timely fashion”. No evidence of provider oversight of this was available. These omitted medications included those for pain relief, nutrient supplements and medicines designed to prevent high blood pressure, for example. Medicines prescribed for the treatment of the symptom of Parkinson’s disease had not been given on one occasion putting the person at risk. There was no evidence the person’s wellbeing had been checked, or effective reporting had been undertaken to recognise this. Prescribed nutrient supplements were not given to one person over the course of two months. This person’s weight had been monitored and assessed as being of normal weight at admission and then eventually assessed as underweight. One person had experienced a health condition which meant their blood pressure was to remain in safe limits following a severe brain haemorrhage. This medication had been omitted on three occasions during 2024 and placed the person at risk. People who were prescribed (Lorazepam) given when they experienced extreme distress had a PRN (when required) protocol in place designed to ensure the consistent and appropriate administration of this medication. Care notes highlighted those occasions when the medication was given, however, strategies to use other methods to manage this anxiety were not routinely used. One individual had been given the medication on 48 times over the period of three months. The recording of the reasons why peop