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Inspection Summary

Overall summary & rating


Updated 22 February 2017

Thornley Leazes Care operates both a care home and domiciliary care service under their registration with the Care Quality Commission. The care home provides accommodation and personal care and support for up to 12 people, primarily with learning disabilities. Some people supported by the provider in both the care home and the domiciliary care settings, were living with dementia. In addition, some people supported with domiciliary care had physical disabilities. There were 12 people living at the care home at the time of our inspection, and a further five people in receipt of domiciliary personal care, in the local Allendale and Catton community areas.

This inspection took place on 10 and 11 November 2016 and it was unannounced. The last inspection we carried out at this service was in January 2015 when the provider was not meeting all of the regulations that we inspected which included the need for consent, safe care and treatment and good governance. The provider submitted action plans linked to each of these breached regulations, stating how and by when they would meet the requirements of these regulations. At this inspection we found improvements had been made in all three of the regulations that had been breached at our last visit.

Thornley Leazes Care does not require a registered manager to be in post under their registration with the Commission, as the registered provider is an individual in day to day charge of the service and the carrying on of the regulated activity. A registered manager is a person who has registered with the Care Quality Commission to manage the service. In this service, the provider is a ‘registered person’ who is actively involved in the service who has legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Concerns identified at our last visit to this service in January 2015 related to the management of medicines and people's finances had been addressed and we were satisfied that measures had been put in place to support people to remain safe. Medicines were now managed safely and some small areas for further improvement were discussed with the assistant manager and registered provider.

Staff were aware of their personal responsibility to report matters of a safeguarding nature and they were knowledgeable about the different types of abuse. People told us they felt safe living at Thornley Leazes Care residential home or in receipt of care from the service on a domiciliary basis, and we found no evidence during our inspection that contradicted this.

Risks within the environment of the care home setting and in people's own homes had been assessed and measures put in place to mitigate these risks. Equipment used in care delivery had been appropriately serviced and checked to make sure that it remained safe for use. A business continuity plan had been drafted for staff to refer to in an emergency, for example if there was a loss of power to the building. Health and safety checks around the building were carried out regularly, including fire safety checks.

Staffing levels within the service were appropriate to meet people's needs and were adjusted depending on people's activities and their desire to access the community. Staff files revealed that recruitment processes were thorough and that staff were trained in areas relevant to the needs of the people they supported. They received appropriate supervision and appraisal and told us they felt supported to fulfil their roles by the registered provider, and the assistant and home care managers.

People received an effective service from staff who were knowledgeable about their needs, likes and dislikes. They enjoyed good relationships with each other. Staff provided person-centred care and understood people's behaviours and personality traits. People told us they were supported to live their lives in the way that they wanted to and that their general

Inspection areas



Updated 22 February 2017

The service was safe.

Medicines were managed appropriately but improvements were needed to ensure all best practice guidance about the safe handling of medicines was followed.

Safeguarding procedures were in place to protect people from harm and abuse.

Checks on the building and equipment used in care delivery were carried out regularly.

Risks that people were exposed to in their environment and their daily lives had been assessed and plans were in place to mitigate these risks.

Staffing levels were appropriate to meet people's needs and recruitment procedures were robust.



Updated 22 February 2017

The service was effective.

The Mental Capacity Act 2005 (MCA) was appropriately applied and applications to deprive people of their liberty lawfully had been made in line with legal requirements.

Staff were knowledgeable about people's needs and people told us they were happy with the service they received.

They were supported to meet their healthcare needs and food served to people was healthy and wholesome.

Staff received regularly and appropriate training and they were supervised and appraised within their roles to ensure they remained competent and delivered effective care.



Updated 22 February 2017

The service was caring.

Staff and people enjoyed good, positive relationships that promoted people's wellbeing.

People told us they felt involved in their care and relatives said they were kept informed.

In practical terms people's dignity and independence was promoted and they were respected. Some conversations between staff needed to be held in more private areas to avoid them being overheard.

Independent advocacy services were available to people.



Updated 22 February 2017

The service was responsive.

People and their relatives gave positive feedback about the responsiveness of the service.

People were given choices about how they lived their lives and they were supported to access activities within the local community.

Care was person-centred and overall care records were appropriately maintained.

Monitoring of care delivery took place and ensured continuity of care for people.

A suitable complaints policy and procedure was in place that was brought to the attention of people and visitors.


Requires improvement

Updated 22 February 2017

The service was not always well led.

Improvements in the quality assurance systems within the service had been made since our last visit. Audits had been introduced and matrices were used to monitor training, supervision and appraisal requirements.

Further improvements were needed, particularly to records and recording systems.

Overall notifications about incidents had been made but some had been overlooked, as had displaying the previous rating given to the service on the company's website.

People and staff gave positive feedback about the registered provider, who strove to fulfil the service's mission statement in the delivery of care.