St Catherines Care Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Information for people to meet their communication needs was not accessible to them. Care plans were reviewed only by nursing staff and was not inclusive of people or their families.

People living at the service did not tell us about how they could make a complaint, but relatives told us they knew how to do this. Some had not had to complain but some had and did not experience any sustained improvements. Complaints records found inconsistently recorded investigations.

People who were reaching the end of their lives received appropriate medical care and relatives were able to spend as much time with their loved ones and had their privacy respected.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives' views on the care provided was mixed. Those who were happy with the care provided, did not refer to care plans. One relative was concerned that part of a care plan involving rehabilitation had not been done, “[Name] had daily exercise from rehabilitation that has never been done.” Another stated, “Staff are mashing [name’s] food up, but we have requested that they just have normal food”. There was no evidence that this matter had been discussed in the care plan or elsewhere.

The personal care needs of people were included in care plans. Staff told us that there was not sufficient time to attend to all the basic needs of people, for example, personal care.

People at times were distressed and anxious. Care plans for one person required staff to use other techniques to prevent such anxious episodes as a first strategy. On occasions where this person was anxious; there was no evidence that these strategies had been followed other than people being given prescribed PRN (when required), medication.

Care plans were reviewed monthly, however, there was no evidence that anyone other than registered nurses reviewed these. There was no care staff input and more significantly, no involvement of people living at St Catherines or their relatives. In addition to this, care plans were overwhelmingly focused on the nursing needs of people with little mention of their social history.

Care plans included details of prescribed medicines and their role in maintaining health. The number of occasions that medicines had not been administered meant that care plans were not followed. For example, one person who had a health condition had not received medication to control blood pressure which put the person at risk. Sample of fluid charts demonstrated that people were at risk of being dehydrated. Fluid charts made no reference to daily targets to ensure people were hydrated.

Some relatives stated that they were happy with the care provided. Others were not. They said despite requesting information, the outcome was that “nothing gets done” and that there no continuity of care. One relative had raised a safeguarding alert in respect of their loved one but despite recommendations made by the safeguarding authority, no progress had been made. For one person, it was recommended by an agency to implement daily exercises as part of a rehabilitation regime. The relative stated that this had not been done.

We did not receive any specific feedback from staff or leaders about care provision and continuity.

Partners stated that action plans had been devised to drive improvement, but that little progress had been made. They stated that concerns remained over significant incident reporting, staffing levels and care plan needs not being met.

Hospital packs were available to ensure continuity of care between the service and hospital if admission was required. Processes are in place for the recording of health issues and outcomes following Doctor appointments. Staff were able to access this.

With relatives’ views and experiences being so varied, this meant that there not everyone received equity of outcomes and experience.

Leaders did not always ensure that people were at the centre of everything they did. The numbers of staff did not match dependency levels and as a result, staff had resorted to a task-based method of working.

There was a lack of effective action to address unreported safeguarding incidents, to ensure appropriate hydration levels and unwitnessed falls prevention.

People did not make any reference to making a complaint, but relatives did. Some relatives told us that they had not had to raise concerns but if they did, they would speak to the manager. Those who had made complaints told us that no meaningful action was taken. One relative said that following a safeguarding investigation, it was recommended that meetings with the keyworker should take place. They told us that this had not happened

There were no processes in place to capture the views of people who lived at St Catherine’s.

A residents meeting was held during one day of our visit. It was not clear if these were regular or had been set up recently. Topics discussed were general and did not go into detail of individuals’ care. There was no evidence that significant events such as accidents or unexplained bruising had involved a meeting with relatives to discuss these. A complaints procedure was in place as well as a complaints log. The log did not always confirm that the outcome of all complaints raised had been recorded or recognised.

People and their relatives told us that there were no barriers to accessing health services or any subsequent access to health services for follow ups.

Arrangements were in place to enable paramedics to be called and for smooth hospital admissions to be undertaken if required. A hospital passport was in place for each person giving an indication of their needs for hospital staff to refer to.

Partners did not comment on accessibility issues.

There was no evidence that barriers in communication had been addressed. People, regardless of their communication needs, did not have access to advocacy services to give them a “voice” in their care. There was no evidence that provider quality assurance audits had included getting the views of people about the care they received. This had not been recognised by the service.



Care records provided evidence that when emergency medical assistance was required by external agencies; this was provided.

People did not make any reference to making a complaint, but relatives did. Some relatives told us that they had not had to raise concerns but if they did, they would speak to the manager. Those who had made complaints told us that no meaningful action was taken. One relative said that following a safeguarding investigation, it was recommended that meetings with the keyworker should take place. They told us that this had not happened

There were no processes in place to capture the views of people who lived at St Catherine’s.

A residents meeting was held during one day of our visit. It was not clear if these were regular or had been set up recently. Topics discussed were general and did not go into detail of individuals’ care. There was no evidence that significant events such as accidents or unexplained bruising had involved an individual meeting with relatives to discuss these. A complaints procedure was in place as well as a complaints log. The log did not always confirm that the outcome of all complaints raised had been recorded or recognised. Concerns that relatives raised with us did not appear on the complaints log.

Relatives were aware if their relations were reaching the end of their lives. This information was relayed to families as people’s health deteriorated and anticipatory medicines had been prescribed. People were able to visit their loved ones at this time and were given privacy.

The service had been proactive in gathering information for each person on their funeral wishes. Compliments on how people in the past had been cared for were received through cards which without exception thanked the staff team for the care of their loved ones.

Best interest decisions and personal choices meant that some people were subject to Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR). These wishes were clearly marked for staff to refer to if required. Care notes clearly identified those who were reaching the end of their lives with evidence in place to take all their wishes and needs into account. The service had attained a certificate in the “Six Steps” to end of life care. This is to enhance end of life care by supporting staff to develop their roles around end-of-life care.