St Thomas' Priory

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in continued breach of legal regulation in relation to people’s safe care and treatment.

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.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not investigate or report safety events.

Staff completed behavioural charts identifying when people were involved in incidents of distress. However, these records were not consistently reviewed or followed up with the people or staff involved. As a result, opportunities to identify lessons learned were missed, and incidents were not always referred to appropriate external bodies, such as the safeguarding team. This lack of follow-up placed people at continued risk of similar incidents recurring, exposing them to potential harm.

Following our feedback, the provider investigated and found this issue occurred on one floor of the home, where procedures for incident management were not followed. While the provider took steps to address this, including introducing a post-incident review system for staff, further oversight was required to ensure consistent monitoring and appropriate action was taken across the service. We will assess the effectiveness of these new systems at our next inspection.

We received mixed feedback from staff regarding the home's approach to learning from incidents and accidents. Some staff reported senior colleagues reviewed incidents with them and shared lessons learned. One staff member said, “We do have incidents, we [staff] complete our reports, and we have a debrief with the registered manager.” Other staff stated they did not receive any form of debrief or support following such events, with one staff member commenting, “Incidents are being reported by staff to the senior, but we hear nothing, nothing happens.” This inconsistency suggests a robust and embedded learning culture had not yet been fully established.

Despite these concerns, people living in the home told us they felt safe. One person said, “I feel safe. I have no reason not to.” Those who experienced accidents, such as falls, told us staff supported them appropriately and safely. One relative told us, “[My family member] had a fall recently and they [staff] called us straight away, the staff helped [my family member] back to bed. They hadn’t hurt themself.”

The provider did not manage or monitor people’s safety, and they did not always maintain safe systems of care.

Clear systems were not always in place to guide staff on how to respond safely in emergencies, such as fire. Existing protocols did not consistently reflect people’s current mobility needs, increasing the risk of unsafe evacuation procedures. This placed people at risk of avoidable harm. Where people required specific health management protocols, such as catheter care, these were not always available.

We observed missing equipment, including pressure-relieving cushions for people assessed as needing them, which increased the likelihood of pressure damage. One person was observed in bed with the bed positioned low to the floor, a crash mattress placed beside it, and bedrails raised. On reviewing the care plan, we noted a previous incident where the person had attempted to climb over the bedrails. We questioned their use. The registered manager investigated and confirmed bedrails were not intended to be raised. Care plans were updated, and staff were reminded of the correct procedure.

Despite these issues, people told us staff knew them well and supported their needs. One relative told us, “My [family member] has an alarm linked to their movements. The staff always monitor [my family member] safely.”

The provider did not work effectively with people or healthcare partners to understand what safety meant to individuals or how to achieve it. There was limited focus on improving people’s lives or protecting their right to live free from bullying, avoidable harm, and neglect. Concerns were not always shared promptly or appropriately.

We reviewed multiple incidents involving people who became anxious and distressed, resulting in verbal threats or physical assaults toward others living in the home. While many incidents were reported to relevant authorities in a timely manner, a review of 3 months of records on 1 floor involving 2 people revealed 10 serious incidents which should have been referred to the safeguarding team and followed up with other professionals. This failure to report posed a significant risk to the safety and wellbeing of those involved and represented a serious breakdown in safeguarding oversight. Following our findings, the registered manager undertook an urgent review and submitted the necessary referrals, most of which were subsequently closed. In response to our feedback, new systems were introduced to strengthen reporting processes and prevent future omissions.

During the inspection, we raised concerns regarding people’s repositioning, moving and handling, and 1 person being prevented from accessing their bedroom due to a locked door. These issues had the potential to compromise individuals’ dignity, autonomy, and physical wellbeing. The provider responded by submitting safeguarding referrals in response to our feedback.

The registered manager submitted Deprivation of Liberty Safeguards (DoLS) applications for people who required this level of protection. We reviewed whether the service operated within the principles of the Mental Capacity Act and found conditions attached to DoLS authorisations were met and legally upheld.

Staff told us they would raise safeguarding concerns with appropriate authorities when required. One staff member said, “I would report any concern to the senior or manager, if they didn’t do anything I would go to CQC or local authority.” However, several concerns identified during our inspection had not been reported.

People told us they felt happy and safe living in the home. However, 1 person reported their call bell was removed by night staff, so they had no way to summon staff, if needed. This was investigated by the manager, a safeguarding referral was made, and a spot check was completed to ensure this was no longer happening.

Staff did not consistently provide care that was safe, supportive, or enabled people to pursue what mattered to them. While we observed staff encouraging people to engage in activities and make their own choices on some floors, this was not consistent across the service.

We observed people who were unable to support themselves out of bed, remaining in bed for prolonged periods. When we asked staff why people were still in bed during the afternoon, staff were unable to provide a clear explanation.

In other areas of the home, we observed staff respecting people’s choice and autonomy. Where people made decisions such as joining in an activity or deciding to eat different meals, we observed staff respect their choices.

Staff told us they aimed to promote people’s rights and choices. However, staff on some floors reported this was difficult due to staffing levels. One staff member said, “It's difficult sometimes, you know people want you to sit and talk with them, but there's not enough time, we are too busy.”

The provider did not consistently detect or control potential risks within the care environment. Equipment, facilities, and technology did not always support the delivery of safe care.

Airflow mattresses were required by some people to maintain skin integrity. We observed how one person’s mattress was faulty, and they told us it had been in this condition since the previous day. No action had been taken until we raised the concern with the provider. The registered manager investigated, identified the need for a replacement, and ensured a new mattress was provided by the end of the same day. In addition, a mattress was incorrectly set for another person’s weight. In response to our feedback, the registered manager implemented a system to prompt staff to check mattress settings regularly, helping to prevent future risks to safety and comfort.

We checked whether people in bed had access to mobility equipment in case of emergency. One person had an incorrect sling stored in their room, increasing the risk of error during transfers. Another person’s sling was missing; it had been stored in a different room. When we checked whether it had been returned, the sling was still missing. On one floor, people moved freely through corridors, however a cupboard meant to be locked for safety reasons was found open. The registered manager responded by closing off this area.

We observed locks on some bedroom doors, including one instance where a person attempted to enter their room while the door was locked. The registered manager removed all locks following our feedback.

External and internal health and safety checks were completed, and action was taken when needed. However, daily walkaround checks required improvement to ensure equipment was functioning, correctly set, and stored safely in the appropriate location.

Staff told us they received health and safety training. People told us they felt staff supported them safely, and relatives said they had observed staff using equipment appropriately. One relative told us, “I have seen my [family member] being safely hoisted into an appropriate chair.”

The provider did not consistently ensure enough skilled and experienced staff were on duty to meet people’s needs safely.

While some areas of the home were adequately staffed, we raised concerns about low staffing levels on certain floors. Feedback from staff was mixed. Some reported having sufficient colleagues to support people safely, while others working in different areas or at different times said staffing levels were inadequate. One staff member who worked regularly on one floor said, “We are fine for staff and it’s getting better.” However, on 2 other floors staff said, “There is just not enough staff on duty to support people safely.” Another staff member said, “Staffing levels are a bit short. We could do with an extra staff member, it's difficult to manage.”

The provider used a dependency tool to determine staffing levels based on peoples’ assessed needs. However, the tool did not accurately reflect people’s current needs or behavioural presentations. The registered manager responded by updating the tool and increasing staffing levels within the identified areas.

We received mixed feedback from relatives regarding staffing numbers. Some felt staffing levels were appropriate, while others said more staff were needed on specific floors and during certain times. One relative said, “I think that there are enough good staff and regular staff.” Whereas another relative commented, “On occasions they could do with more staff, especially at night.” All relatives told us staff were helpful and supportive toward their family members.

Staff were recruited safely and received appropriate training. However, some staff said they lacked confidence when deescalating situations involving people who were highly emotive or distressed. In response, the provider arranged a new face-to-face positive behaviour support course.

The provider assessed and managed infection risks effectively. Measures were in place to detect and control the spread of infection, and concerns were shared with appropriate agencies in a timely manner.

The home environment was clean, well maintained, and free from malodour. We observed staff actively engaged in cleaning routines, including regular touch-point cleaning of high-contact surfaces. This contributed to a hygienic and safe setting for people living in the home.

During our inspection, we identified a crash mat in need of replacement due to visible wear. The provider responded to this feedback and arranged for a suitable replacement to be sourced.

Where appropriate, staff wore personal protective equipment (PPE) correctly and consistently. This included gloves, aprons, and masks, depending on the level of care being provided and the assessed risk. Staff demonstrated awareness of infection control protocols and were observed following hand hygiene procedures.

Relatives told us they felt the environment was clean and hygienic. They expressed confidence in the provider’s approach to maintaining cleanliness and reducing infection risks. People told us they felt their room was clean. One person said, “It is clean, and my bedclothes are clean.”

While overall standards of cleanliness were high, continued monitoring of equipment condition and timely replacement remained essential to ensure IPC measures were fully effective.

The provider did not consistently ensure medicines were managed and documented safely.

Where people required ‘as required’ (PRN) medicines, staff did not consistently record whether the medication had been effective. This lack of monitoring and evaluation placed people at risk, as it remained unclear whether the medicine achieved its intended outcome or whether further intervention was needed.

For 2 people receiving covert medication [where medicines are hidden in food or drink] the method of administration was not documented. This omission increased the risk of inconsistent practice, with covert medicines potentially given in varying ways depending on staff interpretation.

We identified one person with a significant allergy to a specific medicine. While this was clearly stated in their care plan, the medication administration front sheet recorded no allergies, and handover documentation also stated no known allergies. This inconsistency in recording placed the person at risk of harm, as essential information may not be communicated during emergencies. The provider responded to our feedback by updating all relevant documents to include the person's allergy.

Medicines were stored securely and in line with national guidance. Staff told us their competencies were regularly assessed to ensure safe administration. One staff member said, “When medication errors occur, staff have to redo their competencies and reflect on what went wrong and how they will improve.” People living in the home said they received their medicines at the correct time and felt confident in the support provided. One person told us, “I have medication, they [staff] never forget to give it to me.”

Improvements were needed to ensure documentation was accurate, consistent, and reflective of people’s needs, particularly in relation to PRN and covert medication protocols. In response to our feedback the provider carried out further supervision and training for the staff concerned and completed a 'lessons learned' form.