14 Thornhill

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 remained 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 governance.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager did not have a proactive approach to learning and improving safety. Systems used to monitor the service did not always produce records to clearly show what checks had been carried out or what action had been taken to address issues. The lack of records meant it could not be confirmed the registered manager and staff learnt lessons for incidents and events.

Systems for recording and sharing learning were not always robust. Training records were not always well monitored, some training in key areas such as first aid at work and fire warden was out of date.

The registered manager was unclear as to whether this training was mandatory for this small service but had not taken any action to check this or ensure staff completed the training whilst waiting for an outcome.

The registered manager and staff reflected on incidents and shared learning through regular staff meetings and debriefs following incidents. A staff member told us, “We have regular staff meetings, and these are very helpful.”

The provider did not always have effective systems in place to help deliver safe care.

Easy Read Individual Support Plans were available and contained information about people’s routines, care needs and communication approaches to guide staff. However, across the wider records reviewed, care plans, behaviour support plans and risk assessments were not always clear, practical or consistent. They did not always give staff sufficient practical guidance, and there was conflicting information across records. This increased the risk of inconsistent responses during transitions, incidents or changes in need.

Staff worked closely with healthcare professionals and supported people to attend appointments. Professionals told us the service responded well to people’s needs and staff understood the people they supported.

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.

Systems and guidance were not always in place, up to date, or reflective of people's current needs. Although staff supported people in line with their assessed needs, provider guidance and individual STEP plans did not always accurately reflect current practice. This was discussed with the registered manager, STEP team and Adult Residential Management Team, who took action to review and amend guidance during the assessment period.

Staff had received safeguarding training and safeguarding knowledge checks were undertaken to support staff competence in recognising and responding to concerns

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

The registered manager did not always involve people to understand and manage risks.

Risk assessments were not always sufficiently detailed, clear or consistent with other care records. Information relating to restrictions and physical interventions was not always clearly recorded or readily accessible, and records did not consistently demonstrate how people had been involved in decisions about managing risks. In some cases, restrictions identified within risk assessments had not been discussed with the person. As a result, risk management documentation did not always fully reflect people's rights, wishes, independence or involvement in decision-making.

Positive risk taking was promoted. People were involved in discussions about activities, holidays and aspects of keeping safe.We saw examples of people discussing risks associated with some activities and community access and making choices about how they wished to spend their time.

The provider did not always detect and control potential risks in the care environment.

We found some environmental safety concerns, including issues relating to window safety arrangements and other maintenance matters. We discussed these with the registered manager and action was being taken to address some of these issues during our final site visit to the service.

Environmental checks and safety systems were in place. The registered manager recognised these systems required improvement to identify, report and action maintenance and safety risks, and for staff to better understand their responsibilities for keeping the building safe. They acted on this during the assessment.

The environment was generally clean, and relatives gave positive feedback about cleanliness and the condition of the service.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

During the assessment, inspectors identified concerns regarding assurance and oversight of training requirements, including first aid and fire warden training. Additional evidence submitted demonstrates high levels of mandatory training compliance, regular competency assessments, supervision processes and emergency preparedness arrangements, including fire drills, business continuity planning and medication competency checks. However, inspectors were not consistently assured during the assessment that training oversight systems effectively demonstrated compliance and emergency cover arrangements.

The provider generally ensured there was a sufficient number of staff to meet people's needs, and the staff team was stable with low turnover. Staff and relatives indicated that continuity of staffing was a strength, which meant people were supported by staff who knew them well.

Safe recruitment practices were also in place and followed.

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 service environment was clean and tidy, and relatives provided positive feedback on cleanliness. Staff understood how to prevent infections and followed procedures.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff managed medicines safely overall. Medicines were stored appropriately and systems were in place to safe support administration.

The team followed STOMP principles (Stopping Over Medication of People with a learning disability and autistic people) and worked alongside healthcare professionals to adjust medicines, resulting in improved outcomes for people.