St Joseph's Nursing Home

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 good. 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 was in breach of legal regulation in relation to safe care and treatment.

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 demonstrated a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt, and staff confirmed they were included in reviews following incidents and accidents. Examples of lessons learned were shared in newsletters for the service.

Unfortunately, not all lessons learned were sustained. For example, in a safeguarding concern reported in June 2025, lessons included proactive monitoring for a person following a pressure injury. During this assessment, gaps in repositioning charts were identified, meaning those lessons had not been maintained. The registered manager explained there was an issue with syncing on the electronic care planning system where not all recordings were updating. However, we would expect providers to have identified and resolved this issue prior to our visit. The registered manager responded to concerns proactively and introduced daily checks of repositioning charts.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

Staff ensured continuity of care, including when people moved between different services. They reviewed assessment information with clinical staff before admission and used hospital passports containing essential health details during hospital visits or other appointments.

A professional told us, “I do think staff are sufficiently skilled and experienced to care and support people at the home, they are always proactive concerning referring people to the correct health professionals if required.” Staff knew people well and where possible supported people with hospital admissions.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider had a process in place to ensure safeguarding concerns were reported in a timely way and followed up by the registered manager. Staff had received safeguarding training and understood reporting processes. A staff member told us, “If I suspected a resident was being abused or at risk, I would report it immediately to the manager or the designated safeguarding officer. Concerns are documented and investigated promptly.”

The registered manager had oversight of deprivation of liberty authorisation and ensured any conditions were met.

People told us they felt safe. A person told us, “I definitely feel safe, it is a clean environment.” Another person said, “I do feel safe here, staff help me wash and dress.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, systems in place required improvement to fully identify and mitigate risks to people’s care and support.

Staff did not always monitor clinical risk effectively. Monitoring charts such as fluid monitoring and repositioning monitoring were not routinely checked to explore any shortfalls so concerns could be picked up quickly and escalated if required. Following our feedback the registered manager told us they thought there may be an issue with syncing of the system and took action to ensure these charts were monitored daily.

People’s care plans had conflicting information. For example in 1 care plan, different conflicting information about a person’s body mass index was recorded which had implications in the calculation of this person’s risk score. Not all related care plans had anticoagulant risk assessments, however these were sent following the assessment. Despite this staff knew people very well and their related risks. A staff member told us, “I don’t really look at the risk assessment. We have a lot of verbal risk assessments and every morning we do a walk around and if we have a new resident we get a handover from the nurse. Nurses are really good and also been here some time.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During our visit, we identified pressure-relieving equipment where the outer layer was damaged, which could compromise its effectiveness and increase the risk of harm for people at high risk of pressure injuries. Damaged or poorly maintained equipment should be promptly repaired or replaced to maintain safety standards. The audits we viewed had not identified these concerns. However, following the assessment the registered manager sent evidence replacements had been ordered.

We identified out-of-date condiments in one of the kitchen areas. These were disposed of immediately by staff. While prompt action was taken, this indicated routine checks were not sufficiently robust to prevent expired items from remaining in use.

The service had started a refurbishment programme, and we were able to see areas of the service had improved, however further work was needed as we found damage to a person’s armchair and some over bed tables with surface damage.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff told us there were enough staff to meet people’s needs. One staff member said, “It does seem enough, and residents get what they need.” Another added, “We have enough staff, I will always support, and the Nurses are very hands on. We don’t have agency staff unless they are providing 1:1, even those are regular.”

People and relatives were positive about staffing levels in the service. A person told us, “When I press the buzzer, they come reasonably quickly.” Another person told us their buzzer was usually answered within 5 minutes, and any longer staff would apologise for any delays.

Staff were positive about their training and support. A staff member said, “St Joseph’s provides me with sufficient training to meet people’s needs. Practical training undertaken includes fire simulated evacuation exercises and participation in a Virtual Dementia Tour.”

Safe recruitment practices were in place to make sure that all staff, were suitably experienced, competent, and able to carry out their role.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider systems to identify potential infection control risks did not identify all risks. For example, a bathroom marked as out of order was still accessible and had been used for storage. It was filled with belongings from a room and had a jug on top covered in cobwebs and spiders, indicating it had been left unattended for some time. Providers are expected to ensure all areas, including those not in active use, are maintained in a clean and sanitary condition to prevent infection risks.

Toiletries were stored in shared bathrooms, which meant we were not assured people’s individual toiletries were being used. This practice increased the risk of cross-contamination and did not support person-centred care. These were removed at the time of the assessment.

People were happy with the cleanliness in the service. A person told us, “It is quite good, ask for anything you do get it, always clean.” A relative said, “Everywhere is clean, they clean people properly too, even the cleaners they stand and talk to me.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People, relatives, and staff did not raise concerns about medicines management, but we identified shortfalls in the records. When we reconciled medicines, we found numerous discrepancies where stock counts did not match the amounts recorded on the electronic medicines system. These discrepancies meant we could not be assured staff administered medicines as prescribed.

Staff had not identified gaps in both fridge and room temperature checks, which were essential for maintaining medicines integrity. Additionally, risks to people from anticoagulant medicines had not always been incorporated into their care plans, which could increase the risk of harm. Providers are expected to have robust systems to ensure medicines are managed safely, records are accurate, and risks are fully assessed and mitigated.