St George's Nursing Home

Date of Inspection: We commenced this inspection on 23 July 2026 with a visit to the service. Due to the concerns found during our visit we sought assurance from the provider on 30 July 2026 and met with them on 05 August 2026 to share our findings and inform them of the actions being taken. The inspection was concluded on 8 September 2026. This inspection was undertaken in response to recent concerns shared with the Care Quality Commission (CQC).

Since our last inspection published on 15 January 2026, we found the service had not made the required improvements to meet the breaches of regulations and improve the standard of care provided to people. We found the provider was still in breach of 2 regulations in relation to safe care and treatment and good governance. We also identified new breaches of regulations in relation to safeguarding, staffing, medicines management, notifications to CQC of significant events and a poor overall culture.

There was not a proactive learning culture and risks to people were not managed safely. The provider did not follow local authority or CQC safeguarding procedures to ensure people were safeguarded from harm. Incidents where people experienced harm were documented by staff, but these incidents were not always responded to by managers. We identified ineffective monitoring and management of risks associated with dehydration, nutrition, and skin integrity. Records and observations showed some people remained in bed for prolonged periods without access to adequate food or fluids and without regular repositioning. This meant risks relating to dehydration, malnutrition, and the development of pressure ulcers were not consistently identified, monitored, or mitigated, placing people at risk of avoidable harm. The provider had not ensured enough trained staff were on duty to always meet people’s needs. Recruitment checks to ensure staff working in the service were safe to do so were not always carried out. People’s medicines were not always managed safely or administered at the times the prescriber intended. The provider did not ensure the environment was safe, and outstanding fire safety actions from our previous inspection remained outstanding. Staff did not complete regular fire drills or simulated evacuations.

Governance systems to monitor the quality and safety of the care provided were not effectively operated. The provider and management team failed to identify the issues highlighted during this assessment. We sought additional assurances from the provider to ensure the critical risks identified were being monitored regularly and people received care that was safe and appropriate. The provider had not worked in partnership with other health professionals within their community in a positive or proactive manner. A shared culture had not been embedded within the service by the provider to ensure people received appropriate care that met their needs fully. Leadership at all management levels did not support the delivery of safe care for the people using the service. We made referrals to help keep people safe during the inspection because serious concerns were found, including the local authority safeguarding team, commissioning team and the fire service.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

Following the feedback provided to the management team they have provided assurances that some action has been taken to address the shortfalls.