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 inadequate. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service had previously been in breach of the legal regulation relating to safe care and treatment. Incident management had since improved, staffing levels were sufficient to keep people safe and meet their needs, and the environment had improved. As a result, the provider was no longer in breach of this regulation.

This service scored 59 (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 always demonstrate a proactive or positive culture of safety. Lessons were not consistently learned or embedded to support continuous improvement and the development of good practice.

There had been significant improvements in care and support, as well as progress in the organisational culture. However, some concerns from the previous inspection remained. Key areas affecting people’s health, such as repositioning, oral care, and oversight of equipment, still required improvement. This showed a fully embedded learning culture was not yet in place.

Visiting professionals reported positive progress. One professional said, “Overall I have seen positive changes; the continuity of staff is much improved, especially upstairs. There is more leadership on the floor, the nurses are more present, and staff seem to respond more positively to the leadership.” Staff also noted improvements, 1 member of staff told us, “I’ve noticed a difference between the top floor and the first floor; it’s more settled now.”

Lessons from incidents were shared with the staff team, and oversight of incidents and emerging trends had improved. However, staff debriefs following incidents involving distressed behaviours were not always recorded, which limited opportunities for reflection and learning. The provider responded to our feedback by introducing a new system to monitor and record staff debriefs.

The provider did not always work effectively with people or external professionals to maintain safe systems of care.

Risk assessments were in place, but they lacked the detail needed for safe decision‑making. For example, diabetes risk assessments did not always include early signs to monitor, safe blood glucose ranges, or clear instructions for staff when readings were outside these limits. This meant staff did not always have the guidance needed to respond promptly to changes in people’s health.

Feedback from visiting professionals was mixed. Some reported good communication and responsiveness, while others described ongoing difficulties contacting the management team. One professional also noted improvements since the last inspection, particularly in the environment and staffing on the top floor.

People told us they felt safe. However, inconsistent risk assessments and variable communication with external professionals meant the service could not demonstrate safe systems were always in place.

The provider worked effectively with people to understand what feeling safe meant to them and how best to support this. However, concerns were not always shared promptly or appropriately.

There had been improvement in the reporting of safeguarding referrals to the local authority. However, 3 incidents had not been reported to the safeguarding team in a timely manner. Although these incidents were investigated and mitigating action was taken by the registered manager, the delay meant safeguarding procedures were not followed as required. The registered manager told us this was due to oversight and said they were recruiting an additional member of the management team to strengthen oversight. The local authority safeguarding team told us they sometimes needed to chase the provider for further information.

Despite this, people told us they felt safe living in the home. One person said, “I am safe here, the staff come and check on me.” A relative told us, “I feel [my family member] is safe and comfortable here. I can see in their face they are happy and comfortable with the staff.”

Staff were clear about how to raise safeguarding concerns and told us they would report these to the registered manager whenever required.

The provider worked with people to understand and manage risks. However, some risk assessments lacked sufficient detail to guide staff effectively and did not always provide clear instructions for safe care.

Where people declined aspects of their care over prolonged periods, for example, oral care support, there was no recorded evidence showing how staff encouraged the person, escalated concerns, or discussed the potential risks of their decision with them.

Following our feedback during the inspection, the provider updated relevant risk assessments and introduced a new oral care monitoring tool to strengthen oversight and improve documentation.

People told us they had choice and control over their care and support. People also described how adaptations within the environment helped them feel safe.

Staff provided care in a supportive and safe manner and demonstrated an understanding of people’s individual needs. They described how they promoted positive and active risk‑taking in line with people’s preferences. For example, 1 staff member explained how they supported a person who continued to drink alcohol despite this action not being advisory due to their health condition. They were able to describe how risks were monitored and managed to support the person’s independence while maintaining safety.

The provider did not always identify, monitor or control environmental risks effectively. Although improvements had been made to the physical environment, and internal and external checks were completed to monitor the safety of the premises, utilities and equipment, some safety concerns remained.

We found 2 people who required pressure‑relieving mattresses to be set at specific settings; however, both mattresses were incorrectly set. When we returned later in the day, the settings still had not been corrected. This placed people at increased risk of avoidable harm, as equipment intended to protect them was not being used safely. We raised this with the provider, who reviewed both people and ensured the mattresses were correctly set. However, the lack of timely action showed inconsistent oversight of essential equipment. The provider responded to our feedback and introduced a new monitoring system.

Staff told us they took part in regular fire evacuation drills, which supported their understanding of emergency procedures.

The provider ensured there were enough suitably qualified, skilled and experienced staff to meet people’s needs safely. People told us there were sufficient staff available when they required support. One person said, “I don’t have to wait long if I press my call bell. I buzzed at 3.00 am and they [staff] came quickly.”

Staff also confirmed there were enough staff on shift to provide safe care. One staff member said, “There is enough staff, we don’t have to rush.”

Staff training had improved since the last inspection. The provider focused on strengthening staff skills in responding to people who were distressed and developing staff knowledge of dementia. Staff spoke positively about this training and described how it had enhanced their confidence and practice.

Staff were recruited safely. All required recruitment checks were completed before staff started work, ensuring only suitable individuals were employed.

The provider assessed, monitored and managed infection risks effectively. The home was visibly clean, and regular environmental checks were completed to maintain safe standards.

We identified 1 concern regarding the management of reusable plastic medicine dispensers and spoons on 1 floor. These items were not being cleaned and dried in line with safe infection prevention control (IPC) practice, which increased the risk of cross‑contamination. We raised this with the registered manager, who responded promptly and purchased single‑use disposable dispensers to reduce infection risk.

People, relatives and staff told us the environment was clean and well maintained. We observed staff wearing appropriate personal protective equipment (PPE) and using it correctly. Staff also cleaned up spills quickly and effectively, which reduced infection risk and supported safe practice during care delivery.

Infection prevention control audits were in place to monitor infection risks and guide ongoing improvements.

The provider ensured medicines and treatments were safe and met people’s needs, capacities and preferences.

People told us they received their medicines safely. One person said, “Staff help me take my medicines, I can forget.”

Staff told us they received training in the safe administration of medicines, and their competencies were refreshed regularly. One visiting health professional said, “I review medication for all people. They have just changed pharmacy again, which was needed, and they are settling into a new way with this pharmacy. It’s a lot better now.”

Where people received ‘when required’ medicines, protocols were in place.

We observed medicine administration; people received their medicines safely and in a dignified way and medicines were stored safely.