The Manor House Thurloxton

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 good. At this assessment the rating has changed to 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 safe care and treatment, and staffing.

This service scored 53 (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 did not always learn lessons to ensure good practice was embedded. However, the service had a positive culture based on openness and honesty.

We found incidents were recorded without outcomes. Although the managers felt that these were addressed at the time, we found no evidence of this happening. There was no analysis of safety incidents, for example following falls. However, following 1 fall monitoring equipment was introduced to help alert staff when person mobilised.

Staff were positive about the deputy manager’s communication and felt they were kept informed about any incidents or accidents, but that this was mostly verbal. People and staff felt they could easily raise concerns, 1 person told us, "I would speak with [deputy manager] if I was worried."

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. People experienced safe admissions to the service. The deputy manager carried out preadmission assessments with people to ensure their needs could be met before moving in. One relative told us, "Admissions process was smooth, and done quickly” and another said, “[Person] had a trial week.” Staff told us they received a verbal handover from the deputy manager when people were admitted to the service. This ensured people’s needs could be met.

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.

People and their relatives did not raise any safeguarding concerns with us. One person told us, "Yes I am safe here, staff treat me well" and another said, "I feel safe here." One relative told us,"[Person] is safe and secure. If something happens staff are around."

The provider and the deputy manager told us they promoted people’s safety by, “Being present within the service" and they, "Speak with residents regularly." Staff knew about signs of abuse and neglect and felt confident they could raise concerns. One staff member told us, "First port of call would be to speak with [deputy manager]."

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. There was nobody subjected to DoLS at the time of our assessment.

The provider did not always work well with people to understand and manage risks. We identified examples where guidance relating to people's health conditions was not always sufficiently detailed to support safe care delivery. For example, 1 person was at risk of choking but did not have a detailed risk assessment and guidance within their care records. Staff gave inconsistent feedback about their food texture, and we observed during our visit food served was not in line with their care plan. The deputy manager made a referral to the relevant health care professional following our assessment.

We found other shortfalls in risk assessments. For example, 1 person at risk of constipation did not have a bowel management plan within their care records so staff did not have correct guidance about when to escalate risks. Another person who had reduced mobility and was supported to use a vehicle did not have a risk assessment or guidance within their care records around transport. This meant further improvements in risk management and mitigation was required.

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

We found several shortfalls with the safety of the environment. There was no environmental risk analysis which would identify potential hazards to people. There was a swimming pool which could be accessed by people, and the provider had not assessed the risks associated with this. This presented a risk of harm to people, including a risk to life or serious injury.

During our first visit we found water temperatures in people’s rooms was above the recommended safe temperature and presented a risk of scalding. There were no window restrictors on the first floor and products hazardous to health were accessible to people. When we returned for a second visit, we observed that window restrictors were now fitted and hazardous products were now stored safely in a locked cupboard. The deputy manager informed us they had ordered thermostatic mixing valves to maintain safe water temperatures, but these still needed to be fitted. They told us this action would be completed by the end of September 2026.

Hot surfaces such as radiators and pipes were uncovered throughout the home; this placed people at risk of scalding on hot surfaces. There were no risk assessments identifying how any of these risks were mitigated.

Some people used wheelchairs and walking frames, but staff had not checked them to ensure they were safe to use. The premises had a stair lift, and 1 person had a profiling bed, however there was no evidence they had been serviced and certified safe to use.

The provider commissioned a fire safety assessment which was carried out in May 2026. The provider had not ensured all actions from this assessment were completed. During the assessment, the deputy manager provided us with an action plan to address the outstanding actions. However, these were yet to be completed. People did not have Personal Emergency Evacuation Plans (PEEPs)within their care records and staff were therefore unsure how they would evacuate people in the event of an emergency. Fire drills were not carried out despite being recommended by the fire safety assessment. This put people at risk in the event of an emergency situation. Staff did not receive training in fire safety. However, staff completed tests on the fire alarms weekly to ensure they were working effectively.

In response to our concerns, the deputy manager told us they planned to implement ongoing checks and audits on the health and safety of the home. At the time of our assessment these had yet to commence and would require time to become embedded and demonstrate their effectiveness.

The provider did not always make sure staff received training appropriate to their roles. They did not always make sure staff received formal supervision and development opportunities.

The provider did not ensure all staff had supervisions and appraisals. However, staff did feel supported by the deputy manager who was available onsite for support. There was no evidence of how staff were inducted into the service. Staff did not receive training to ensure they were able to carry out their duties safely. For example, manual handling and fire safety. Some staff did not have the Care Certificate or a recognised health and social care qualification. The Care Certificate is a nationally recognised set of standards that ensures health and social care workers have the skills, knowledge, and behaviours needed to provide safe, compassionate, and high-quality care. This meant the provider could not be assured staff had the right skills and knowledge to provide safe care to people.

People and staff generally felt there were enough staff on duty, and staff knew people well. We did not observe any delays in care provision; staff responded to people’s needs in a timely way.

There were some gaps in safe recruitment of staff. We reviewed 2 staff files and found that a full employment history was missing for both. This meant they could not be fully assured staff were suitable to care for vulnerable people. However, service leaders had ensured other checks such as Disclosure and Barring Service (DBS) checks, and references had been conducted. The deputy manager immediately acted on our feedback and provided us with an action plan to improve recruitment by the end of September 2026 and began putting relevant documents in the staff files.

The provider began acting on our feedback and planned to implement a new training system, which included signing staff up to complete the Care Certificate. They also scheduled supervisions for all staff.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading. We observed that the home was clean throughout and staff had personal protective equipment (PPE) available. One relative told us, “Home is very clean." The laundry room was small; however, the provider had a schedule to minimise cross contamination. Red bags were available for soiled clothing and staff told us they would wash soiled clothes at high temperatures. This minimised infection risks to people.

The provider did not make sure that medicines were managed safely.

Staff did not monitor the storage temperatures for medicines therefore; the provider could not be assured medicines were stored within the recommended range. Failure to store medicines within the recommended temperature parameters can affect their effectiveness.

The provider did not have a system to record the receipt and safe disposal of medicines, which limited oversight of medicines entering and leaving the service.

There were 3 gaps in the medication administration records (MARs) for 1 person’s pain relief which meant we could not be assured the person received these medicines. The deputy manager assured us these omissions had been followed up, but outcomes were not recorded. There was no system for stock checks of medicines, therefore discrepancies in people’s medicines may not be effectively identified.

Staff did not risk assess high risk medicines such as lithium and blood thinners This meant potential side effects may not be identified or responded to appropriately.

Staff did not receive training in medicines and did not have their competencies checked. This meant the provider could not be assured staff had the required skills to administer medicines.

The provider did not have any risk assessments for people who self-administered their medicines and the provider did not have any systems to monitor this.

However, medicines were securely stored and people had access to their prescribed medicines.

Where appropriate people were supported to self-administer their medicines which promoted their independence.

The deputy manager immediately acted on our feedback and introduced an electronic MAR system, and a medicines policy with the aim to ensure the service had safe medicines management.