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We are carrying out a review of quality at Thornley Leazes Care. We will publish a report when our review is complete. Find out more about our inspection reports.
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Inspection report

Date of Inspection: 7, 8 May 2014
Date of Publication: 6 June 2014
Inspection Report published 06 June 2014 PDF | 104.93 KB


Inspection carried out on 7, 8 May 2014

During a routine inspection

We considered all the evidence we had gathered under the regulations we inspected. We used the information to answer the five questions we always ask;

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, their relatives, staff supporting them and from looking at records.

Is the service caring?

We saw that people were supported by kind and attentive staff who displayed patience and gave encouragement when supporting people. Our observations confirmed that staff promoted independence whilst ensuring that they offered assistance to people when required. People told us that they were happy with the care and support they received from the service. One person said, "I like it here" and "The staff are fine." One person's relative said, "I trust the staff. I know that they are going to take care of 'X'."

People (and their relatives and staff) told us they pursued many activities and this was evident during our inspection. Some people were supported with community based activities such as shopping, and to attend social events such as going to the theatre. This showed that the provider promoted people's community involvement and well-being.

Is the service responsive?

People's care needs and any potential risks that they may be exposed to were assessed before they received care and support from the provider. In the care home setting, the provider had arrangements in place to review people's care records regularly and they assured us that amendments would be made to people's documentation as their needs changed to ensure they remained accurate and any issues were promptly addressed.

Staff told us, and records showed that where people required input into their care from external healthcare professionals, such as occupational therapists or doctors, or where, for example, their weight or behaviours needed to be monitored, they received this care.

There was an effective complaints system in place although records showed that no complaints had been received whilst the service has been under the provider's ownership.

Is the service safe?

There were enough staff on duty to meet people's needs. Records showed that staff were appropriately trained to ensure that they were equipped with the correct skills and attributes to carry out their jobs effectively and safely.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLs) which applies to care homes. The provider confirmed that no applications for a deprivation of a person's liberty under the Mental Capacity Act 2005 have been submitted to the local authority safeguarding team. We discussed the recent supreme court judgement handed down on March 2014 in the case of 'P v Cheshire West and Chester Council and another' and 'P and Q v Surrey County Council', about what constitutes a deprivation of liberty. The provider confirmed they would contact their local safeguarding team in light of this judgement, for further advice on their responsibilities and the arrangements they now need to put in place, for people in their care.

We looked at how the provider managed medicines and found that this was appropriate. Medication administration was safe and records were complete. In addition, the obtaining, storage, safe keeping and disposal of medicines was safe.

The home was generally clean although some equipment and furnishings that people came into contact with were not clean. Infection control procedures that were in place were not always followed by staff and some of these procedures did not follow national best practice guidelines. This was putting people at risk of infection. We have set a compliance action and asked the provider to tell us what they are going to do to meet the requirements of the law in relation to maintaining a clean and hygienic environment and following infection control national best practice guidelines.

We found the building was not well maintained because damp and mould was present in communal areas and within people's bedrooms. In addition, entry into the building was not secure and therefore any person(s) may have been able to enter the building undetected. People were not accommodated in a safe environment. We have set a compliance action and asked the provider to tell us what they are going to do to meet the requirements of the law in relation to maintaining a safe and appropriate environment.

People's care needs had been assessed but their care records were not always well maintained. For example, we saw that people who lived at Thornley Leazes had care plans and risk assessments in place, and those people in receipt of care in their own homes did not. There was a risk that people may not receive safe care, as staff did not always have individualised care plans and risk assessments to refer to. We have set a compliance action and asked the provider to tell us what they are going to do to meet the requirements of the law in relation to maintaining appropriate care records.

Is the service effective?

People told us they were happy with the staff who cared for them and they met their needs. One person said, "The staff are alright." Another person told us, "I like staff." It was evident from speaking with staff and through our own observations that staff had a good knowledge of the people they cared for and their needs.

Certificates were available that showed staff had received appropriate and up to date training to meet people's needs effectively.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. A care manager and a district nurse that we spoke with told us they were confident that the provider delivered a good care service and kept them updated and fully informed of any changes in people's care needs.

A quality assurance system was in place and the provider gathered the views of people and staff about the service they delivered. One relative had commented in a questionnaire, "I have always thought the residents are well looked after."

Staff told us they were clear about their roles and responsibilities. The provider had a range of policies and procedures in place which gave direction and instruction to staff. Staff and management meetings were held as and when required. Health and safety checks were carried out regularly and where applicable in line with national or best practice guidelines.