Thorp House

Thorp House is a nursing home, providing accommodation, personal and nursing care to up to 41 people. The service provides support to people with nursing and residential care needs, as well as people living with dementia. At the time of our inspection there were 39 people using the service.

The service consists of a large extended building set over 2 floors. There were a number of communal areas on each floor and a corridor from the ground floor led to 6 self-contained apartments.

At the time of our inspection, the service was experiencing a COVID-19 outbreak, with all people with a positive test result being supported to remain in their bedrooms and receiving individualised care and support to reduce the risk of the spread of infection. Some staff were also on sick leave. These circumstances were taken into consideration in the approach taken to completing this inspection.

People’s experience of using this service and what we found

People lived in a visibly clean and comfortable care environment, with sufficient numbers of trained staff to meet their individual needs, wishes and preferences in a person-centred way. People received their medicines as prescribed, and staff supported a number of people living with complex medical care needs, to maintain good standards of health and overall quality of life.

Since our last inspection, improvements had been made to the detail and quality of people’s care records, with evidence of involvement from people and their relatives in the development. People were encouraged to lead active and purposeful lives, with access to activities on a 1:1 and group basis. People were able to make their bedrooms personalised, with their own furniture and possessions of personal importance.

Staff were observed to be kind, caring and respectful towards people, and welcoming when visitors and professionals arrived at the service. Additional safety measures were in place to facilitate visiting during the current COVID-19 outbreak, to prevent the risk of people feeling socially isolated. People were also supported to be part of the local community, enabling people to improve their spiritual and social well-being.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Changes to the registered manager and deputy manager had happened since the last inspection, this had resulted in positive improvements in the level of governance and oversight of the service, to ensure people consistently received good quality, safe care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement with breaches of the regulations. (Published 15 April 2019).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of the regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. As a result, we initially undertook a focused inspection to review the key questions of safe, responsive and well-led only. However, after our inspection visit, it was agreed we would also inspect the key question of effective to ensure we could proportionally reflect all areas of improvement found at the service. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from require improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Thorp House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Thorp House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home can accommodate up to 41 people. The home supports people with nursing and residential care needs and supports people living with dementia. At the time of the inspection there were 39 people in the home as two were in hospital at that time. The home was full and requests were being received for beds when they became available.

The home was a large extended building set over two floors. There were a number of communal areas on each floor and one corridor from the ground floor led to five self-contained apartments. The main kitchen and laundry facilities were on the ground floor.

The home had a registered manager in place who at the time of the inspection had been registered with the Care Quality Commissions for just over two years. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The last inspection in January 2018 found the provider in breach of four regulations. The home was found to require improvement overall and in all key questions of safe, effective, caring, responsive and well led. Breaches were found in how the provider managed safeguarding concerns and whistleblowing, how the provider upheld the dignity and respect of people living in the home, how risks were managed and how the provider audited and managed systems to identify concerns and continuously drive improvement.

At this inspection we found action been taken to meet the requirements of the regulations and two of the previously breached regulations were now fully met. We found the provider and all staff at the home were very conscious of upholding people’s dignity and ensured people were respected at all times. We also found all staff had received training in safeguarding and when we spoke with them they displayed a good understanding and knowledge of when and where to report concerns. We found action had been taken to improve how risks were managed but some further action was required. People’s needs were not assessed at point of change and action from the changes was not always evident or easy to find. This regulation remained in breach.

We found the same with the systems and processes in place for auditing and monitoring provision of the service that still required improvement. We found some issues were found in the systems used by the provider and there was still a settling in period for new technology. This included a lack of shared understanding by everyone as to how to use the systems and gather the right information from them. This information was crucial to effectively monitor and audit how they were improving the service received by people living in the home. This regulation remained in breach.

Additional concerns were also found that led to a further three breaches of the regulations. There was a lack of formal consent being gathered from people in the home and the lack of decision specific capacity assessments and best interest decisions. This was specifically the case for restrictive practice such as bed rails and when medicines were given covertly. This means when they were given to people in their food or mixed into drinks to ensure people took the medicines they needed to stay healthy. People are not supported to have maximum choice and control of their lives and whilst staff do support them in the least restrictive way possible; the policies and systems in the service do not support this practice to be completed in line with the requirements of the regulation.

The second breach noted on this inspection was that there were not enough staff on through the night and the allocation and role of staff during the day required more thought. Senior carers were undertaking roles of kitchen assistant at breakfast time and carers were delivering food to people. This was at a time when people needed most support to get ready for the day.

We also found people were not involved in reviews of their care plan. This meant they were not offered opportunities to tell staff when they required more support, and some people told us they were now needing more support but were not receiving it We saw some care plans identified risks and showed how people should be supported to minimise them. We saw occasions when this did not happen. This included someone being offered biscuits as snacks when they were diabetic and additional support not being offered to another when their blood sugar went higher than acceptable levels. People were not always receiving person centred care because they had not been involved in determining what support they needed.

We have made three recommendations following this inspection, which include; ensuring a suitable audit tool is used to assess the suitability of the environment for the people living in the home. Any action identified should be completed in a timely manner to ensure the building and environment is supporting people living there. We have recommended the provider ensures actions are taken around medicines including the completion of topical medicines administration records, availability of protocols for as required medicines and immediate action to ensure medicines are kept at the correct temperature when stored. Lastly, we have recommended work is completed to assess and meet the preferred preferences of people including their diet, where they would like to spend their time, the decoration and use of the premises and the support and care they receive.

Comprehensive care plans ensured people received the support they identified they required. More staff would enable the care plans to be completely up to date. Information required to assess changing needs prior to additions to the care plan was missing. Once included there would be a better measure if changes in support provided reduced risks and met associated needs.

People told us they liked the staff and they were given choices throughout their day. There was a programme of activities which was well developed and delivered. There would be scope for an additional coordinator to deliver more of the programme in place to a greater number of people in the home.

Staff and people in the home had developed positive relationships and the keyworker system due to be launched would better embed this.

We found staff were sufficiently trained to meet people’s needs and had been safely recruited. Once in post staff sought advice and support as required to deliver care and support safely.

The building was well maintained and professional testing of equipment was undertaken. Appropriate action had been identified on how to support people in the event of an emergency. The home had effective systems in place to manage and control the spread of infection.

Whilst the mealtime experience required more thought and preferences of what and how people ate were still to be acquired. In general, people were supported with good nutrition and hydration. Where risks were identified action was taken.

Professional support was acquired as needed to support people with long term conditions and their general health. This included visiting chiropodists, opticians and diabetic nurses.

You can see what action we told the provider to take at the back of the full version of the report.

This comprehensive inspection took place on 14 and 17 November 2017. The first inspection visit was unannounced.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection of this service on 14 and 18 April 2016, we found that the service was good in all areas. The registered persons did not therefore need to take any action to comply with regulations. At this inspection, we found that the quality and safety of the service had declined and it required improvement in all areas. There were four breaches of regulations.

The service people received was not as safe as it should be. We found that staff and the registered manager did not act as expected to refer a concern that someone had been assaulted. A concern about rough handling was also raised with us that could place a person at risk of harm. The level of knowledge of staff and their awareness of local procedures for safeguarding people needed to improve. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014.

There were additional concerns relating to the management of risks, which systems for assessing safety had not identified. This included concerns for trip hazards within the home and in relation to moving and handling, which made some people feel unsafe. This was a breach of Regulation 12 of the Health and Social Care Act (Regulated activities) Regulations 2014.

There was good practice in other aspects of the safety of the service. This included managing people’s medicines safely, with minor anomalies being identified and addressed. Arrangements for cleaning the home contributed to reducing the risk that an outbreak of infection would not be contained.

People were not always treated with respect for their privacy and dignity. This was either through omission when staff did not offer prompt intervention to promote people's dignity, or by action taken that directly compromised privacy and dignity. This was a breach of Regulation 10 of the Health and Social Care Act (Regulated activities) Regulations 2014.

Standards in the service had declined since our previous inspection. Governance and leadership of the service failed to sustain the good outcomes for people we found at our last inspection. Systems were not effective in proactively identifying and addressing the concerns we found. The need to ensure the service returned to good and the slippage in arrangements to properly and effectively evaluate the service represented a breach of Regulation 17 of the Health and Social Care Act (Regulated activities) Regulations 2014.

You can see the action we have told the provider to take in response to these four breaches of regulations at the back of the full version of the report.

Staff did not always receive the support and supervision they needed to support people competently. This included shortfalls in the clinical skills of nurses and gaps in training or assessments of competence for staff. Between the two of our inspection visits, the management team developed an action plan for addressing the shortfalls we pointed out.

People received support and advice about promoting their health including with their diet. We received reassurances during inspection that the quality of their mealtime experiences would be reviewed to see how these could be improved, in line what people told us. We were also assured that apparent shortfalls in people’s food and fluid intake were the result of lack of accurate use of the provider’s new electronic recording system and further training would be provided.

People felt that most staff were kind and caring in their attitudes. During our interviews with staff we found that they were aware of people’s likes and dislikes. In some cases, working to build a picture of these that could be incorporated into plans of care to guide other staff. There were plans, following the introduction of the new electronic care planning system, to look at how people could be more formally involved in reviewing their care and making decisions about it.

People’s experiences of care were sometimes task focused rather than responsive to them as individuals. However, improvements were being made in relation to enabling people to engage in hobbies and activities that were of interest to them following the recent appointment of a staff member allocated to these. There was a system for managing complaints about people’s care and ensuring they were kept informed about findings. The registered manager had plans to review the arrangements for consulting better with people about their wishes at the end of their lives to ensure these were met.

At the time of our inspection the service did not have a registered manager at the service, although a new manager had been appointed and would be commencing shortly. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Since the last registered manager left the service in November 2015. The service had experienced two managers come and go in a relatively short time and had not been in post long enough to become registered. During this time the service had not reported these events to the Care Quality Commission. The uncertainty around the management and leadership of the service had been further complicated by the senior clinical post also becoming vacant. The regional manager for the area had begun to oversee the service and had based themselves there for the past few months. During this time a new deputy manager and clinical led nurse had been appointed which had started to bring back stability to the service. The operations manager had recognised the difficulties around staff recruitment, reporting structure to identify and resolve issues and staff support through regular training and supervision. They had implemented a great deal of work to address these issues.

People were being protected from the risk of abuse as established senior care assistants and care staff were knowledgeable in this area and training had been planned for all staff to attend in the near future. There were emergency plans in place at the service and we saw that people had risk assessments which was reviewed regularly and as required.

People were now supported by a sufficient number of suitably qualified nursing and care staff. The service had appointed permanent nursing staff to replace agency nurses. The provider had ensured appropriate recruitment checks were carried out on staff before they started work. Staff had been recruited safely and completed an induction procedure for working at the service. Further on-going training has been arranged for all staff and a person had been appointed to lead upon the activities at the service.

The provider had systems in place to manage medicines and people were supported to take their prescribed medicines safely. Although the service appeared to have sufficient nursing and care staff day to day needs of people,the service did not use a dependency tool to determine how many staff were required to be on duty to meet people’s needs.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Appropriate mental capacity assessments and best interest decisions had been undertaken by relevant professionals. This ensured that the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, DoLS and associated Codes of Practice. The Act, Safeguards and Codes of Practice are in place to protect the rights of adults by ensuring that if there is a need for restrictions on their freedom and liberty these are assessed and decided by appropriately trained professionals. People at the service were subject to the Deprivation of Liberty Safeguards (DoLS). Staff had been trained and had a good understanding of the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Understanding and empathic relationships had been developed between people and staff. Staff responded to people’s needs in a compassionate and caring manner. People were supported to make day to day decisions and were treated with dignity and respect. People were given choices as far as possible and were supported and enabled to be as independent as possible in all aspects of their lives. A respite service was also provided. The regional manager had limited the number of people using the service with more complex needs to allow nursing staff to settle into their roles and all staff developed the necessary skills required..

The staff knew people well and were trained, skilled and competent in meeting people’s needs. Supervision and appraisals were planned. People were encouraged to be involved in the planning and reviewing of their care and support needs.

The service worked with other professionals so that people’s health needs were managed appropriately with input from health care professionals. People were supported to maintain a nutritionally balanced diet and sufficient fluid intake to maintain good health. Staff ensured that people’s health needs were effectively monitored. The deputy manager had worked with the catering team to provide soft diets and pureed meals to be appetising in appearance and taste.

People and staff told us there was now an open culture and the management staff of the service were approachable and supportive. The focus of the new management team was to provide care that was centred on the individual.

People were supported to report any concerns or complaints and they felt they would be taken seriously. People who used the service, or their representatives, were encouraged to be involved in decisions about the service.

There were systems in place to check the quality of the service and take the views and concerns of people and their relatives into account to make improvements to the service. Audits were carried out to determine the views of staff, relatives and people who used the service.

Is the service caring?

People told us that they received consistent and respectful support from care and nursing staff and felt able to make choices and changes when required. Staff told us that they were well supported and supervised so that they could provide safe care and support to people.

Is the service responsive?

We saw that people's personal care and social support needs were assessed and met. This also included people's individual choices and preferences as to how they liked to be supported. People we spoke with told us that they felt well cared for and observations we made during the inspection confirmed this to be the case.

Is the service safe?

Risk assessments regarding people's individual care and support needs had been improved to ensure there were measures in place to minimise any potential harm to people using the service. Carers understood their roles and responsibilities in making sure people were protected from harm. The provider had taken appropriate action to ensure that there were appropriate levels of staff to meet people's needs at all times. Improvements had been made to ensure safe infection control procedures were in place. We saw that Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) assessments had been undertaken where appropriate and that staff received training regarding these issues.

Is the service effective?

We found that nurses and care staff were knowledgeable about people's individual care and support needs. People that we spoke with confirmed that staff provided consistent and kind support. Care planning documentation was well coordinated and reviewed to ensure that individual care and support needs were being met. The acting manager confirmed that support documentation was regularly audited to ensure it met people's assessed needs.

Is the service well led?

The home does not have a registered manager in place. However, a registered manager application has been received and is currently being assessed. Staff that we spoke with told us that they felt well supported by the management team and were regularly trained to safely provide care and support. People that we spoke with told us that they felt they were listened to and support was consistently and safely provided. Quality assurance systems were in place to regular audit the care and services provided. Surveys were carried out to gather opinions from a people using the service, relatives and healthcare professionals to ensure that ongoing improvements could be made.

We found concerns that people may not always receive care and treatment in line with their plan of care because staff members did not all have access to this guidance.

Staff were knowledgeable about what to do if they saw or heard abuse and were able to explain different types of abuse.

There were effective systems in place to reduce the risk and spread of infection, however we found that these systems were not always followed by staff.

We found that the provider was in the process of taking additional steps to improve the environment for people who used the services.

Staff told us that they felt they could not always provide the care needed. There were not always enough qualified, skilled and experienced staff to meet people's needs.

We spoke with two people who used the service and two visitors who told us that the staff looked after people very well. One person said, "When you buzz for the toilet they (staff) come, you get well fed and they look after you very well". However, we noted that assessments carried out contained differing information to that specified within a person's care plan, which did not provide staff with clear information about a person's needs.

We saw that there were systems in place to ensure safety checks were carried out on a regular basis. However, people who used the service, staff and visitors were not protected against the risks of unsafe or unsuitable premises.

Comments and complaints received were used to develop the service and were discussed at staff meetings so that learning could be shared.