St Catherines 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

The governance and management of the service was poor. Audits were not effective. Issues such as poor fluid recording, unwitnessed falls, skin tears and unexplained bruising had been identified but no appropriate or effective action had been taken in response to these events to protect people and minimise or prevent the risk of harm.

Medication audits had overlooked multiple occurrences of non-administration of medication, the need to review the frequency of use of the medicine Lorazepam and the recorded reasons for using this.

The service was working with partners to drive improvement but there did not appear to be any progress with this.

This service scored 25 (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 have a clear vision and set of values to promote high quality care for people Staff told us that “taking care of all the older residents is the main thing we do”. Others did not consider that there was a shared vision other than “cost-cutting and reducing staffing levels as a result, people are at risk". Staff told us there was an established culture which had led to a lack of teamwork and direction.

The manager sought to create an open-door policy. Views on the governance of the service was mixed. Some staff felt supported by the manager. They told us, “I do yes I think the manager is very helpful –[Name] helps when we ask” and “The manager is very fair”. Others said, “We are not listened to”.

Staff had received training to enable them to carry out their role. yet this was not always put into practice. For example, safeguarding training had been received by staff yet there were shortcomings in recognising and reporting events especially by senior managers. There was limited evidence of any team meetings to allow information-sharing. amongst staff teams and no evidence of any debriefs following incidents.

The manager had taken over the role since our last visit. They felt supported by the organisation. The manager had received recent support from a Quality Director who had sought to model good managerial practice.

Staff were concerned about the running of the service by the provider. They were concerned that resources such as staff the maintenance of the building and investment would not be prioritised. They considered senior managers in the organisation were not fully committed to supporting vulnerable people.

Members of the management and nursing teams had identified outcomes for people that needed improvement. Despite this, this recognition had not resulted in better outcomes for people, lessons were not learned and there was no opportunity for reflection.

A whistleblowing procedure was in place, yet not all staff understood the steps to take to use this or knew about what this entailed. Our visits generated contact from staff and relatives expressing concerns about the service and they did not feel that their views had been listened to or acted upon.

Systems of reviewing accidents and incidents were not consistently transparent as many safeguarding events had not been appropriately referred to safeguarding authorities as care concerns or for independent investigation.

Staff felt that while they did not have any concerns about equality, they did not always feel included in the running of the service. They felt there was a divide between their everyday experiences of providing care and senior management overview of the quality of the care.

Staff had received training in equality and diversity. Issues identified through audits made general conclusions about the need for staff “to be more vigilant”, “staff to ensure correct recording of fluids” and “nurses to ensure timely ordering of medication.” It was not clear how these comments were relayed to staff, and they did not consider other factors that may be contributing to these shortcomings.

Leaders gave an overview of audits and governance checks that were in place. Daily “Flash” meetings were held. These did not always include the names of attendees (as required by company policy) and provided repetitive and unclear information. There was no indication how comments related to staff performance were to be addressed. Home manager reports were also completed but these again repeated previous issues, key reviews of people’s rooms were missing and sections left blank.



Oversight of the quality of care was overseen by senior managers in the organisation. These consisted of emails from the service manager and others relaying gaps in various records that needed to be addressed. Such audits did not include an actual visit from senior managers to look at the environment or to talk with people and the staff team. We were advised that written reports were done by a senior manager following visits but despite a request for this information, we did not receive these.

Audits were not always accurate or reflective of actual care practice. Medication audits had not included reference to non-administration of medicines, recording of PRN medication administration or the use of PRN as a first step to prevent distress and anxiety for some individuals.

Audits of accidents and incidents were limited to reasons for why people were having unwitnessed falls and senior management had not reviewed incidents to determine other contributory factors or whether they needed to be referred to safeguarding teams or CQC be notified.



Digital care plans included a list of missing actions. On the 19 November 2024, 40 actions/interventions had been missed by the staff team. These included basic interventions, for example, such as, repositioning people, cleaning equipment, oral care and checking on their welfare. One person who had experienced 18 unwitnessed falls in recent months, had not been checked on 7 occasions therefore leaving the person at risk of harm.

People and relatives told us that activities were in house and made no reference to access to community facilities. People were able to access in-house activities yet other people who did not wish to be involved, did not appear to have any individual activity sessions which left them at risk of isolation. Relatives were aware of health issues that affected their loved ones and received feedback about appointment and outcomes. Some relatives were concerned that some events such as running out of medication, had not been immediately reported to them.

Leaders did not demonstrate transparency in their duty to report adverse events and this had not been detected through governance processes. Governance had also not identified the experiences of staff, people and relatives of current staffing levels and their impact. Governance had not identified the over-emphasis on nursing needs and had not recognised the social needs of people. Where shortcomings had been identified, actions were not effective as the same events happened repeatedly.

Partners continued to raise concerns regarding the quality of care provided. They were aware of deficiencies in the safeguarding reporting systems, staffing levels and governance of the service. Local and Health authorities were supporting the service to drive improvements.

The number of potential safeguarding events were not shared with partners. Notifications of key events were not always reported to CQC. Any partnership working was confined to health issues.

Staff were not familiar with quality assurance tools used by the management team. There was no evidence that staff had the opportunity to be debriefed following incidents or that reflective practice was encouraged.

Processes identified improvements required in the provision of care, but these were not effective as events such as unexplained injuries, unwitnessed falls, skin tears, medication non administration and fluid intake of people were still happening.

4 breaches of regulation identified at our last visit. One in respect of recruitment had been addressed. This inspection found 3 repeated regulations in governance, safe care and treatment and staffing. 2 more breaches in nutrition and hydration and safeguarding people were identified at this report. Overall, the service is rated as inadequate.