14 Thornhill

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance.

This service scored 54 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

There was a positive and supportive team culture. Staff turnover was low, staff worked well together, and managers were seen as approachable and supportive. Regular staff meetings supported discussion and information sharing. The stable and supportive culture helped staff maintain consistent relationships with people.

The registered manager did not always embody the culture and values of their organisation.

Governance and oversight systems did not consistently provide assurance that risks, documentation concerns and service shortfalls would be identified and addressed in a timely manner. Inspectors identified a number of concerns during the assessment which existing monitoring arrangements had not identified. Whilst leaders demonstrated commitment to supporting staff and maintaining service quality, oversight arrangements were not consistently effective in assuring compliance and driving improvement across the service.

The registered manager was visible, approachable and supportive, and staff feedback regarding leadership was positive. One person told us,“I feel the [Registered Manager] is very supportive and approachable and always there to support us with anything we need.” This helped build trust in leadership and contributed to the positive team culture described by staff. Additional evidence demonstrated training monitoring arrangements, competency assessments, supervision systems were in place.

The provider had a culture where people could speak up; however, this was not consistently supported by structured systems. formal systems to capture, analyse and learn from feedback were not always robust, and some feedback mechanisms were outdated or not regularly used. This limited the provider's ability to demonstrate how feedback was systematically reviewed and used to drive improvement. We discussed this with the registered manager who said they were taking action to address this.

Staff told us they felt able to raise concerns through a range of mechanisms including supervision meetings, annual performance reviews, probation reviews, regular staff meetings and direct discussion with managers. Relatives also said they felt able to contact the service and raise concerns if needed.

The provider and management team valued diversity in their workforce and ensured they followed best practices guidance. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Mandatory equality and diversity training was in place for all staff, with refresher training to maintain awareness of protected characteristics and discrimination. Staff told us they were treated with respect and that diversity was valued. The management team were aware of their responsibilities under equality legislation and aimed to make reasonable adjustments where required.

The provider did not have effective governance, management and sustainability systems in place. The governance systems were not robust or consistent.

The provider had governance systems in place, including audits, incident reviews and oversight processes. Additional evidence submitted demonstrates that restrictive interventions used were recorded within incident records and reflected interventions identified within people's STEP plans. However, governance systems failed to identify the shortfalls found during this assessment including poor quality records, and environmental concerns. This meant they could not be assured that the service consistently operated in a safe and effective manner.

The registered manager discussed how they completed some checks and audits at regular intervals. However, they did not record the findings or outcomes of these checks and audits, and action plans were not developed to address any shortfalls. This meant there was no information for staff to refer to, or evidence sufficient action had been taken to address the issues found.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service worked effectively with professionals such as GPs and dentists, and people were supported to attend health appointments and maintain family relationships. Relatives and professionals both described communication positively.

The provider did not always show that learning and improvement led to lasting changes. Governance systems had not identified a number of the concerns found during this assessment, and the service had not achieved a rating of good in all areas at its previous two inspections, indicating that previous improvements had not always been sustained.

There was some evidence of learning and development. Staff reflected on practice through meetings and could request additional training. One staff member told us, “There is also the opportunity to request further training if you think it is beneficial to you and your role.”Additional information showed the provider had management forums, incident review processes and quality improvement initiatives in place, which had led to improvements such as changes to risk assessments and monitoring processes.

However, governance arrangements were not always effective. Audits and checks were carried out but were not consistently recorded, and there was limited evidence of actions being followed up. Feedback was not always gathered or used to support improvement, and quality assurance processes had not identified all of the issues found during the assessment, including concerns relating to documentation, environmental risks and oversight. As a result, it was not always clear how learning led to planned, monitored and sustained improvements in the service.