- Care home
14 Thornhill
Assessment report published 8 September 2026
Contents
Ratings
Our view of the service
Date of assessment: 1 June to 23 June 2026. 14 Thornhill is a residential care home that supports up to 6 people with learning disabilities and autistic people. At the time of the assessment there was 6 people using the service. We completed this assessment as part of our routine programme.
We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We found the provider only partly met the principles of right support, right care and right culture. Right care was seen in the way staff treated people day to day. However, right support and right culture were less consistent because communication approaches, management oversight, environmental safety and person-centred planning were not always effective.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations relating to consent and governance. The provider has been asked to produce an action plan explaining how these issues will be addressed.
Systems used to support people's care, safety and wellbeing were in place and staff demonstrated a good understanding of the people they supported. Additional evidence submitted demonstrated that Individual Support Plans, Easy Read documentation, STEP plans, healthcare planning systems, governance arrangements, training oversight processes and organisational learning systems were in operation during the assessment period. Staff worked proactively with healthcare professionals, supported people to access healthcare services and activities, and generally provided care that reflected people's preferences and individual needs. The staff team was stable and people benefited from support from staff who knew them well.
However, whilst systems and documentation were present, they were not always consistently recorded, clearly structured or sufficiently robust to provide effective assurance. Care planning, risk management, governance records and decision-making processes did not always clearly evidence how people's needs, preferences, rights and outcomes were consistently assessed, reviewed and monitored. Governance systems had not consistently identified or addressed all of the concerns found during the assessment. As a result, improvements were required to ensure that person-centred care, oversight arrangements and outcome monitoring were consistently evidenced and embedded across the service.
We also found concerns about consent and the use of the Mental Capacity Act. Mental capacity assessments were not completed for specific decisions, and best-interest decisions were not always made consistently. As a result, systems were not always effective in protecting people’s rights, safety and wellbeing.
At the previous inspections in 2016 and 2019 shortfalls were identified in how the service was operated and the registered manager’s oversight of the home. We continued to find systems for monitoring outcomes and improving the service were not effective and lessons were not learnt.
Feedback was not always formally collected or reviewed, and there was limited evidence to show that lessons learned from incidents or feedback had led to lasting improvements.
We saw many examples of compassionate care and positive relationships between staff and people using the service.
People were supported by a caring and stable staff team who knew them well and treated them with kindness, dignity and respect. People were supported to access healthcare and stay connected with family, friends and their local community. Staff worked well with healthcare professionals to meet people’s needs and respond to changes in their health and wellbeing.
People's experience of this service
People and their relatives spoke positively about the care and support provided at the service. They consistently described staff as caring, reliable and knowledgeable. Additional evidence demonstrated that people had individual support plans, communication guidance, health action plans and personalised activity arrangements in place. People were supported to access healthcare services, community activities and opportunities to develop practical skills and independence. Relatives consistently described communication as open and responsive and felt able to raise concerns if needed.
People benefited from support from a stable staff team who knew them well and understood their preferences, routines and support needs. Staff supported people to make day-to-day choices about activities, meals, routines and aspects of their care, and there was evidence of consultation regarding activities, holidays and some aspects of risk management.
However, whilst staff knowledge and support were strengths of the service, documentation did not always clearly demonstrate how people's preferences, communication needs, aspirations and outcomes were consistently recorded, monitored and reviewed. Some aspects of care planning, communication support, future planning and decision-making required improvement to ensure people’s experiences, rights and outcomes were consistently evidenced through records and governance systems. As a result, people's generally positive experiences were not always fully supported by clear, consistent and person-centred documentation
Relatives told us staff understood people’s needs and quickly noticed any changes in their health or behaviour. They described good relationships with staff and said communication was open and effective. People were supported to access healthcare services and stay in touch with family members and other important people in their lives.
Relatives and staff told us there were enough staff to meet people’s needs, and people received consistent support from staff who knew them well. Staff described a positive workplace with regular team meetings and supportive managers.
People and their relatives said they felt comfortable raising concerns and knew how to make a complaint if needed. Most said they had not needed to complain but felt confident that any concerns would be listened to and acted on.
Where people were unable to fully share their views, we used observations and feedback from relatives and professionals to understand their experiences. We saw staff supporting people in a kind and respectful way and encouraging them to take part in activities.
Overall, people received kind and compassionate care from a dedicated staff team. However, improvements were needed to make sure systems and ways of working were used consistently, so that care is always person-centred, clearly recorded and supports people’s rights, independence and inclusion.