- Care home
St Thomas' Priory
Assessment report published 10 December 2025
Contents
Ratings
Our view of the service
Date of Assessment: 13 August to 15 September 2025. The service is a residential care home providing nursing care and support to adults of all ages, including adults with physical disabilities, mental health issues and people living with dementia.
The provider did not consistently ensure safe care across the service. Systems to manage risk, incidents, and safeguarding were not always effective or embedded. Staffing levels were not adequate to support people safely within some areas of the home. Staff knowledge of behaviour management and risk reduction varied, with some staff lacking confidence due to gaps in training and staffing levels. Equipment was not always maintained or set correctly, and risks to people were not always managed safely. Medicine records were not always completed safely. While infection prevention and control measures were generally well implemented, daily checks and equipment audits needed strengthening.
The provider did not consistently deliver effective care and treatment. Care plans were not always updated to reflect people’s current needs, and staff did not consistently follow evidence-based practices, particularly in relation to moving and handling. Inconsistent recording of people’s support was identified, with gaps in documentation around oral care and repositioning. While staff worked with external professionals and supported people to live healthier lives, inconsistent reporting and oversight impacted the quality of care. Mental capacity assessments and best interest decisions were completed appropriately, and staff promoted choice and consent in line with legal requirements. Improvements were made in response to feedback, but further action was needed to embed effective care delivery across the service.
The provider did not consistently deliver care that upheld dignity, respect, and compassion. While staff showed kindness and people shared positive experiences, there were concerning examples of infantilising language, lack of discretion, and failure to respond to peoples expressed wishes. Environmental barriers limited independence. Staff wellbeing and enablement were mixed, with some staff feeling unsupported.
The provider did not consistently deliver person-centred care. Care plans were not always reflective of people’s current needs, and communication tools were not consistently used. People faced unequal access to activities, especially those with mobility or behavioural needs. The environment lacked dementia-friendly features and emotional stimulation, particularly for those imminently at the end of their life. While some inclusive practices and community engagement were observed, care plans did not reflect people’s goals, preferences or identities.
The provider did not consistently demonstrate effective leadership, governance, or a person-centred culture across the service. Failures in oversight, staffing, care planning, and incident management placed people at risk and compromised the safety, dignity, and responsiveness of care. The provider acted on all feedback and introduced new systems; we will review the success of these systems in the next inspection.
The provider was previously in breach of four legal regulations: Dignity and Respect, Safe Care and Treatment, Fit and Proper Persons Employed, and Good Governance. Following the inspection, sufficient improvements were identified in relation to Fit and Proper Persons Employed, and the provider was no longer in breach of this regulation. Although some progress was noted in Safe Care and Treatment and Good Governance, further concerns were identified, and the provider remained in breach of these regulations. Similar concerns were also found in relation to Dignity and Respect, and this breach continued.
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.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
People's experience of this service
People living in the home generally told us they felt safe and well supported by staff. They described staff as kind and responsive. People shared examples of staff respecting their choices, including decisions about daily routines and activities. Relatives gave mixed feedback on staffing levels, with some saying there were enough staff and others highlighting shortages at certain times or on specific floors. Despite this, all relatives told us staff were helpful, supportive, and maintained a clean and homely environment. They expressed confidence in infection control practices and felt their family members were cared for in a safe setting.
People told us they felt well supported and that staff understood their needs. They spoke positively about the care they received, including support with meals, health appointments, and daily routines. Relatives shared similar views, saying they had seen improvements in their family members’ wellbeing since moving into the home.
People told us staff were kind and generally supportive, and some described warm, respectful interactions that made them feel safe and valued. However, our observations found people experienced occasions where they were ignored or not listened to, and moments where dignity and autonomy were not upheld. These observations demonstrated further action was needed to embed a culture of respectful, person-centred care across the service.
People and their relatives shared mixed experiences regarding the responsiveness of care. Many felt informed and involved in decisions about daily life and described enjoying activities. However, our observations found staff did not always follow care plan guidance, which compromised effective communication. People who could not easily transition between floors or leave their beds faced limited access to meaningful activities, contributing to unequal experiences. These accounts highlight both positive engagement and areas where person-centred care was not reliably delivered.
Relatives felt the registered manager was responsive to concerns and acted on suggestions, and some relatives described a culture that promoted choice and autonomy. However, these positive views were not consistently reflected in practice.
While the people we spoke to expressed that they were generally happy with their care, our assessment found elements of care did not meet the expected standards.