This inspection took place on 8 March 2017 and was unannounced. This meant the registered provider and staff did not know we would be visiting the service. A further two days of inspection took place on 13 and 15 March and these were announced.
Thistle Hill is registered to provide nursing care for up to 85 younger adults or older people, who may be living with dementia or a physical disability. The home is divided into three units. The Deighton unit provides care for up to 41 people who may be living with dementia. The Ripley unit provides care for up to 24 older people who require general nursing care and the Farnham unit provides care for up to 20 younger adults with disabilities. At the time of this inspection, there were 61 people living at the service.
There was a registered manager in post who had registered with the Care Quality Commission (CQC) in July 2016. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At the last comprehensive inspection on 26 July 2016, we identified breaches of regulations. The registered provider had failed to deploy sufficiently qualified and competent staff and effectively monitor and assess the quality of the service being provided. We found that staff did not have the competencies and skills to care for people safely and the needs and preferences of people were not always adequately reflected in care practices and documentation. We asked for and received an action plan telling us what the registered provider was going to do to ensure they were meeting the regulations.
The service was placed into the low levels concerns process with the local authority in September 2016 due to the number of concerns which had been raised by visiting professionals and CQC. At the time of this inspection, Thistle Hill were no longer in the low levels concerns process as the local authority had recognised improvements that had been made.
At this inspection, we found the registered provider and registered manager had begun to implement their action plan and stead progress was being made. We found that the registered provider was still struggling to recruitment permanent staff and the use of agency staff was still high, although this had reduced in recent months. We found some concerns still outstanding including the deployment of staff and a continued breach of one regulation relating to good governance.
You can see what action we told the provider to take at the back of the full version of the report.
Overall, people told us they felt safe. Staff understood how to safeguard people from abuse and were confident the registered manager would deal with any concerns raised appropriately. Referrals had been made to the local authority safeguarding team when required.
People, relatives and staff we spoke with expressed mixed views regarding staffing and the continued use of agency staff. We saw from the rotas that staffing levels were based on the provider’s assessment of people’s needs and occupancy levels but staff were not always deployed effectively.
Risk assessments had been developed and contained relevant information. However, we found that these were not always in place when needed. Accidents and incidents had been thoroughly recorded and appropriate action had been taken to reduce the risk of reoccurrence.
We found gaps in medicine administration records and some of the staff we spoke with were not aware of the correct procedure to follow if they identified any concerns. The administration of topical medicines, such as creams, was not always recorded. Medicines were stored safely and staff competency assessments had been completed.
We have made a recommendation about the management of some medicines.
Safe recruitment procedures had been followed. Recruitment files showed that appropriate checks had been made on the suitability of the employee and staff had received a thorough induction when they joined the service.
Staff had completed a range of training and specialist training had been provided when relevant. We saw that supervisions had begun to take place and staff we spoke with confirmed this. However, the supervisions had not been completed as frequently as the registered provider's policy stated. Annual appraisals had not yet taken place.
Care plans we looked at contained a range of capacity assessments, but the amount of detail was inconsistent. We found that appropriate capacity assessments were not always in place regarding the use of physical interventions. Staff told us they knew what ‘Deprivation of Liberty Safeguards’ (DoLS) meant and the implications for people of having a DoLS in place.
People were supported to maintain a balanced diet. People's weights were monitored and recorded on a monthly basis. We observed lunch time routines on all three units and found that support was provided in a dignified way. People had mixed views regarding the quality of the meals on offer. We could see there was a shortage of staff in the kitchen and other staff, such as the activities coordinator, were being utilised to cover the short fall.
Care records contained evidence of close working relationships with other professionals to maintain and promote people’s health. We could see that referrals to these professionals had been made in a timely manner and these visits were recorded in people’s care records. People confirmed staff were proactive in seeking professional advice.
We saw that staff responded to people’s needs in a timely manner but this was not always consistent on the North Deighton unit due to the deployment of staff. Staff explained to us how they respected a person’s privacy and dignity by keeping curtains and doors closed when assisting people with personal care, and by respecting their choices and decisions.
Care plans were produced to meet individual’s support needs and were reviewed on a regular basis. Care records contained person-centred information but this was not always up to date.
People were aware of how to make a complaint and told us that the registered manager listened to concerns raised. However, we found that complaints had not always been managed appropriately. A copy of the registered provider’s complaints policy was displayed at the service.
People had mixed views about the activities on offer at the service. On the first day of inspection the activities coordinator had been requested to support kitchen staff so there were very little activities taking place. We saw evidence such as photographs which showed activities were on offer.
People and staff spoke positively about the registered manager and recognised the improvements that had been made. Staff felt supported and were confident in approaching the registered manager with any concerns. The registered manager had begun to seek feedback on the service being provided from people, staff and relatives.
We found some of the quality assurance systems were working well, but others needed to be improved to ensure people received a consistent, quality service. Notifications had been sent to the CQC as required by legislation.