St Josephs

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 62 (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 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 to continually identify and embed good practice.

The provider had developed a culture where staff worked together to learn from things that went wrong. Accidents, incidents and complaints were investigated with actions taken to mitigate risk and prevent recurrence. This included reviewing care plans, risk assessments and processes as well as retraining staff, when needed. Staff meetings were held to discuss best practice and lessons learnt. A staff member shared, “I feel like as a whole everything works great. Amazing communication between staff and people. Great team leaders and managers. Nice atmosphere and an environment that allows you to grow and learn with no stress.”

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. We saw evidence in people’s care records of visits and referrals to health and care services, where required. Information was shared and reviewed to ensure people’s needs were met.

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 using the service and their relatives told us they felt safe with the staff. A relative commented, “[Family member] told us that they didn’t think they could look after themselves for much longer. We found this place and [family member] liked it from the first time they saw it. [Family member] is much safer here where there are people around them. All the staff are lovely with them.”

Safeguarding systems were established. Staff had good understanding of safeguarding procedures and were able to describe how to recognise and respond to signs of abuse, demonstrating awareness of their responsibilities. A member of staff shared, “Whether I was afraid for a person’s safety, or another worker, I would probably first talk to a team leader and then my managers if I had to. There have been instances where I wasn’t sure how to go about a situation, and I had to talk to someone, and I never felt unheard or like I wasn’t taken seriously.” Another staff member shared, “If there was a safeguarding concern, I would let the home manager know about this and ensure that steps are being followed and actions are being undertaken.

The provider did not always work well with people to understand and manage risks. Staff provided care to meet people’s needs that was supportive, but this was not always effectively and consistently planned or recorded. For example, people who were at risk of weight loss, or who had experienced weight loss, were not consistently offered additional food and snacks appropriate to their nutritional intake and care needs. The registered manager took immediate action to address this following our inspection visit.

We saw risk assessments were in place and regularly reviewed. One member of staff told us, “We always have access to up-to-date risk assessments and care plans on our devices which are clear and detailed.”

Staff supported positive risk-taking, enabled people to achieve a balanced quality of life between the service and their home environment.

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

The environment was not well maintained to an appropriate level of cleanliness, with some areas observed to be in a poor state of repair. Carpets and soft furnishings were stained and were in need of replacement. We shared our concerns with the registered manager, who recognised our concerns and told us there were plans to undertake refurbishment works, however these had been scheduled for January 2026 to meet people and their relatives’ preferences.

Despite these concerns there was evidence of good health and safety as well as fire safety practice. Regular fire drills were undertaken, all people had up-to-date Personal Emergency Evacuation Plans (PEEPs), a fire risk assessment had been completed, and staff had undertaken relevant training.

We received some mixed feedback about the staffing levels. Some staff did not always feel that they had enough time to talk to people and spend time getting to know them. We also observed, on occasion, in some areas of the home; staff were not readily available to support people and provide them with person centred care. The provider identified this to be a staff deployment challenge and took immediate action to address this ensuring staff were co-ordinated effectively.

We received mixed feedback from some people’s relatives that the home could, on occasion, benefit from more staff, however, other relatives were more positive telling us, “When I’m there, staff seem to be around in the lounge. I’ve never seen anyone left alone if they need help.” And, “I can’t speak about nights but there’re always staff around in the lounge and dining room.”

The service employed agency staff to support with any staffing gaps. Some staff told us it was challenging to work alongside multiple agency staff; however other staff were positive that the provider sourced agency staff to support. One staff member told us, “Even when we are short staffed the managers and team leaders have made sure to call people from agency so [people can receive their care] on time.” The provider told us how they had significantly reduced the need for agency staff through the recruitment of permanent staff. They told us there were consistently enough staff available, however, staff sickness at weekends was a particular challenge.

People were supported by staff who had been recruited safely. Pre-employment checks included obtaining references and checks with the Disclosure and Barring Service (DBS). The DBS helps employers make safer recruitment decisions and help prevent unsuitable people from working in care services. People and their relatives told us staff were well trained, “I’ve been involved with caring for a long time, so I know a bit about it! I’ve never seen any staff be awkward or uncertain when helping a resident. Training is only part of it though and the staff I see really seem to be happy working with older people.” Another relative commented, “All I see is staff who have clear ideas about how to help people, they are really nice people.”

Some areas of the service were unclean, the service was not being effectively deep cleaned to ensure people were protected from the risk of infection for example carpets and some soft furnishings were heavily stained and dirty. The provider took immediate action to address these concerns, with deep cleans being carried out and plans for refurbishment across the service on a phased approach considering people’s preferences.

The provider maintained good supplies of PPE, staff had completed infection prevention and control training, and relevant policies were in place to guide infection risk management.

The service had recently been awarded a five-star rating for the kitchen following a visit from an environmental health officer in April 2025.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider was aware of technology problems within their electronic medicines system and was in the process of making organisational wide changes to make improvements. There was no evidence at this inspection that people were not receiving their medicines as prescribed. We found that topical medicines were not dated when opened and were not being stored securely to ensure people could not access them and potentially cause themselves harm, however, the provider took immediate action to address this. Staff who were responsible for administering medicines were trained and had their competency assessed.We observed good staff practice in the administration of medicines including higher risk medicines requiring additional checks.