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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The service was previously in breach of legal regulation in relation to people’s safe care and treatment. Enough improvements had been made at this assessment and the service was no longer in breach of these regulations.

This service scored 69 (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 had a positive culture of safety based on openness and honesty. Staff listened to concerns about safety and safety events were investigated, reported and used to promote learning and improvement. Leaders continued to support a culture of openness, with incidents, medicine errors and safeguarding concerns reviewed and learning shared through supervision, competency assessments, team meetings and governance processes. Staff told us they felt able to raise concerns and described a supportive, learning-focused culture. Following concerns identified at the previous assessment, the service had reviewed its recording systems and reintroduced paper-based monitoring for medicines and repositioning records while wider system issues were addressed. We saw evidence of lessons learned being tracked and discussed through governance arrangements. However, governance systems had not consistently identified or addressed all environmental and record-keeping issues in a timely manner, meaning improvements were not always sustained and further work was required to embed learning across the service.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider worked effectively with healthcare professionals and partner organisations to ensure people experienced safe and coordinated care. Regular clinical reviews, multidisciplinary working and effective handovers supported continuity of care and timely responses when people's needs changed. Staff worked closely with GPs, dietitians, tissue viability nurses, speech and language therapists and hospice services to support positive outcomes for people. Records demonstrated referrals were made appropriately and recommendations from healthcare professionals were implemented, helping to ensure people received safe and effective support throughout their care journey.

The registered manager shared a positive example of how staff worked closely with a multidisciplinary team to develop a personalised care plan tailored to a person's goals, preferences and abilities. Through coordinated support and regular review, the person made significant progress and was able to return to the community to live independently.

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. People and relatives consistently told us they felt safe at the service. One person said, “Yes, I feel safe, there is someone here 24/7. In the night, if I am in pain or need the bathroom, they are around.” A relative told us, “I think [person] is more than 100% safe here.”

Staff received safeguarding training and demonstrated a good understanding of their responsibilities. One staff member told us, “I would look for unexplained bruises or injuries, changes in behaviour, signs of neglect, poor personal care or if a resident seems frightened or withdrawn. If I had any concerns, I would make sure the resident was safe and report them immediately to the senior care assistant, nurse in charge or the registered manager, following the safeguarding policy.”

Safeguarding concerns were appropriately reported and investigated, with the service working in partnership with the local authority and other agencies to protect people from harm.

We found the service was working within the principles of the Mental Capacity Act 2005. Where people were subject to DoLS, appropriate authorisations had been sought and monitored, and staff understood their responsibilities in supporting people's rights and freedoms.

The provider worked with people, their relatives and relevant professionals to identify and manage risks in a way that promoted independence and reflected people's preferences. Care plans included information about risks relating to mobility, nutrition, hydration, skin integrity and end-of-life care, and staff were able to explain how people were involved in decisions about their care and support. One staff member told us, “Care plans and risk assessments help me understand each resident’s needs, preferences and risks. I follow them to provide safe care while encouraging residents to do as much as they can for themselves.” Staff worked closely with external professionals, including GPs, tissue viability nurses and hospice services, to ensure people received appropriate support when risks increased.

The registered manager recognised previous concerns regarding the effectiveness of clinical risk monitoring and explained that issues with the electronic recording system had affected oversight of medicines and repositioning records. In response, paper-based recording systems were introduced to strengthen monitoring while technical issues were addressed. The registered manager told us, “We have reverted to paper MAR charts and repositioning records whilst improvements are made to the electronic system. We will continue to use these until we are confident the Wi-Fi signal is robust.” This demonstrated leaders had identified potential risks and taken appropriate action to maintain safe monitoring arrangements while longer-term improvements were progressed.

The provider maintained a safe environment for people, staff and visitors and had systems in place to monitor the safety and upkeep of the premises. During the assessment, we identified some environmental concerns, including damaged furniture, worn flooring in the laundry room and sash windows that were not operating as intended. Leaders were aware of these issues and had taken action to address them through the provider's refurbishment and maintenance programmes. For example, the laundry flooring had been escalated for replacement, with completion scheduled for 7 September 2026, and arrangements had been made for the overdue Electrical Installation Condition Report (EICR) to be completed by 28 August 2026. Whilst some improvements had not been completed at the time of our assessment, leaders responded promptly to feedback, demonstrated an understanding of the associated risks and were able to evidence plans to address outstanding actions. This showed a commitment to maintaining a safe environment and driving continuous improvement.

The provider made sure there were enough qualified, skilled and experienced staff to meet people's needs safely. People and relatives spoke positively about staffing arrangements and the support they received. One person told us, “I feel very safe, to know there is someone around when I press my buzzer,” while a relative said, “The staff are very good and know exactly how to look after [person].” Staff also told us there were generally enough staff to support people safely, with agency or bank staff used when additional support was needed.

Safe recruitment processes were followed, including employment history checks, references, right to work verification and Disclosure and Barring Service (DBS) checks before staff commenced employment. Staff received supervision, competency assessments and training to support safe practice and effective care delivery. Leaders also promoted professional development opportunities; for example, the deputy manager was undertaking a Level 5 qualification to further develop their leadership skills.

The service's overall training compliance was 83.10%, which was below the provider's expected standard. The registered manager explained this was partly due to the recent introduction of two additional mandatory training courses, Environmental Awareness and Safeguarding Children, which had been assigned to all staff and impacted the overall compliance figure. The registered manager demonstrated awareness of this and had implemented a clear action plan, including daily monitoring of the training matrix, management oversight and defined timescales to improve compliance.

Staff described positive teamwork and spoke positively about the support they received from managers. They told us leaders were approachable, provided guidance and encouraged learning, which helped them work together effectively to provide safe care that met people's individual needs.

The provider assessed and managed the risk of infection. They detected and controlled the risk of infection spreading and shared concerns with appropriate agencies when required. People and relatives spoke positively about the cleanliness of the service. One person told us, “It is quite good, ask for anything you do get it, always clean,” and a relative said, “Everywhere is clean, they clean people properly too, even the cleaners they stand and talk to me.”

Staff received infection prevention and control training and were able to describe the measures they took to reduce the risk of infection, including effective hand hygiene, appropriate use of personal protective equipment and outbreak management. Regular audits and monitoring processes were in place to identify and address infection prevention and control risks, helping to ensure people were protected from avoidable harm.

During the assessment, we identified concerns regarding the condition of the flooring within the laundry area. Worn and damaged flooring can be more difficult to clean effectively and may increase the risk of contamination if surfaces cannot be maintained to an appropriate standard. The registered manager had recognised this risk and included refurbishment of the laundry area within the service improvement plan. The issue had been escalated to the provider's estates team following the inspection, with progress being monitored and a target completion date of 7 September 2026 set. This demonstrated the provider had taken action to improve the environment and further strengthen infection prevention and control arrangements.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences by involving them in decisions about their care wherever possible. Since the previous assessment, improvements had been made to medicines management processes. The provider had reintroduced paper-based medicines records while wider system issues were addressed, and we saw evidence of regular medicines audits, stock checks, competency assessments and investigations where errors had occurred. Actions arising from medicines audits were followed up through supervision and additional competency reviews to promote learning and reduce the risk of recurrence. People and relatives did not raise any concerns about the way medicines were managed and staff demonstrated a good understanding of safe medicines administration, storage and reporting procedures. We found medicines were stored securely and records reviewed showed appropriate action had been taken when discrepancies or errors had been identified.