St Thomas' Priory

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to overall governance at the service.

This service scored 36 (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 embed a person-centred culture across the service. Observations and feedback indicated staff did not consistently uphold people’s autonomy, preferences, or communication needs. In a number of instances, peoples’ requests for assistance or information were ignored, and dignity was compromised through indiscreet communication and lack of timely responsiveness.

These concerns were not identified or addressed through the provider’s quality assurance or monitoring systems, showing ineffective oversight and limited accountability.

Feedback from staff was mixed. Some staff reported the organisational culture promoted autonomy and choice, while others expressed, they did not feel listened to and lacked resources to support people safely and effectively. This inconsistency demonstrated how staff did not always share the same understanding or approach, which led to an absence of shared understanding or direction among the staff team. Relatives generally felt the service aimed to promote choice; however, this was not always observed in practice.

Overall, there was a clear gap between what the provider thought was happening and what we actually observed, showing the need for stronger leadership, clearer values, and better systems to make sure care is truly person-centred.

The provider did not demonstrate effective leadership or robust quality assurance in monitoring the delivery of care. Failures in oral health support, equipment safety, skin integrity management, moving and handling practices, incident reporting, safeguarding referrals, and emergency evacuation planning were not identified or addressed through internal governance systems. These omissions placed people at risk of harm and compromised both the safety and effectiveness of care delivery.

Feedback from staff regarding leadership was mixed. Some staff reported leaders were present and approachable, while others described feeling unsupported, particularly following incidents involving distressed behaviours. This inconsistency suggested a lack of cohesive leadership and insufficient emotional and operational support for staff.

Relatives told us they felt the registered manager was approachable. One relative said, “I know who the manager is. They are amazing and approachable.”

People and their relatives told us the registered manager responded to concerns and acted on suggestions. While this demonstrated some elements of compassionate leadership, the broader governance and oversight arrangements did not ensure safe, person-centred care across the service.

Staff did not always feel confident to speak up or assured their voice would be heard. Although a whistleblowing policy was in place, its implementation was inconsistent. Some staff told us they had raised concerns but saw no resulting action, which led to feelings of frustration and a lack of trust in the process. Other staff reported feeling supported to speak up and said their concerns were acknowledged and addressed. One staff member told us, “The whistleblowing policy is clear, the registered manager will always take concerns seriously.”

The absence of a consistently supportive and responsive environment for speaking up limited opportunities for learning and improvement. It also risked undermining staff morale and the overall effectiveness of the service’s governance arrangements.

The provider did not consistently promote an inclusive and equitable culture for staff working within the service. Staff experiences varied significantly.

Some staff described divides between staff team who consistently worked across different floors of the home. Leaders in the home told us they tried to maintain consistency for people using the service, by keeping familiar staff in place.

One staff member told us supervision sessions were not constructive, describing them as opportunities for leaders to address poor practice rather than support professional development. Another staff member said they felt ill equipped to respond to people during episodes of distress, suggesting gaps in training and emotional support.

In contrast, other staff described a more inclusive experience. Some staff described feeling well supported by the provider, with one example highlighting compassionate leadership during a time of personal difficulty. The variation in staff experiences indicated the provider had not embedded a consistent approach to workforce equality, diversity and inclusion. A more proactive and transparent strategy was needed to ensure all staff feel valued, supported, and empowered to contribute to high-quality care.

The provider did not establish clear responsibilities, defined roles, or effective systems of accountability and governance. Decision-making was not informed by the best available information regarding risk, performance, or outcomes, nor was this information shared securely with relevant parties when appropriate, particularly in relation to safe care, treatment, and dignity.

Staffing levels were not responsive to people’s changing needs, and oversight of dependency assessments and care planning was insufficient. Staff reported low staffing numbers in 2 areas of the home, and at a specific time, staffing levels were reduced despite repeated incidents occurring during that period. Review of the dependency tool showed it did not accurately reflect the current needs of people, and care plans lacked detail regarding behavioural risks.

The registered manager told us they were unaware of these incidents and behaviours, and senior staff had not followed incident procedures. Following our feedback, the provider increased staffing levels, addressed gaps in incident reporting, and updated care plans. However, these actions were reactive and did not reflect a proactive or sustainable approach to governance.

Failure to monitor, evaluate, and respond to staffing pressures placed people at risk of harm and highlighted a lack of effective oversight. Care records were not consistently accurate, risk assessments were not routinely updated, and staff lacked clear guidance to deliver safe, respectful, and person-centred care.

The provider responded to our concerns by introducing new systems to monitor and audit incidents. We will assess the effectiveness of these systems during the next inspection.

The provider did not consistently demonstrate an understanding of their duty to collaborate and work in partnership, which limited the ability of services to operate seamlessly for people. Opportunities to share information and learning with external partners were not always taken, and collaboration for improvement was inconsistent.

Following incidents involving distressed behaviour, the provider did not routinely report concerns to the safeguarding team or involve relevant professionals. This lack of engagement with external agencies reduced opportunities for coordinated care and risk management.

Despite these concerns, we received positive feedback from visiting professionals. One professional told us the provider was responsive, and another noted improvement had been made within the home. These comments reflected some progress and willingness to engage, though this was not consistently embedded across the service.

A more structured and proactive approach to partnership working was needed to ensure people receive safe, joined-up care and benefit from shared expertise across health and social care networks.

The provider did not prioritise continuous learning, innovation, or improvement across the organisation or within the wider system. There was limited evidence of creative approaches to delivering equality of experience, outcomes, or quality of life for people using the service. The provider did not actively contribute to safe, effective practice or engage with research to inform service development.

During the previous inspection, breaches of legal regulations were identified. While some improvements had been made, concerns remained regarding safe care and treatment, dignity and respect, and overall governance. The level of improvement was not sufficient to demonstrate consistently safe practice.

Lessons were not routinely identified or applied following incidents, which limited opportunities to improve practice and equip staff with appropriate skills and behavioural strategies. Concerns raised during the previous inspection regarding care plans containing conflicting information were found again, indicating a lack of sustained learning and effective oversight.

Staff told us they felt ill-equipped to respond to incidents and some reported feeling undervalued. One staff member stated, “Any concerns we raise are shut down.” Others expressed frustration at the absence of clear strategies to manage distressed behaviours, describing how such behaviours continued without resolution.

These accounts suggest the provider had not embedded a culture of reflective practice or continuous improvement. The absence of structured learning from incidents and lack of investment in staff development contributed to inconsistent care and reduced confidence in managing complex needs. The provider responded to areas of concern by introducing new governance systems to monitor the service. These changes were reactive and did not reflect a culture of proactive improvement. We will review the effectiveness of these systems at the next inspection.