Archived: Thornbury Care Centre

Updated 30 March 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 26 January 2016 and 1 February 2016 and was unannounced.

The inspection was carried out by one inspector and an expert-by-experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed information we held about the home, including the statutory notifications we had received from the provider. Statutory notifications are changes, events or incidents the provider is legally obliged to send us within required timescales. We also contacted the local authority commissioners for the service and the clinical commission group (CCG).

We spoke with eight people who used the service, seven family members and three health professionals. We also spoke with the registered manager, deputy manager and three care staff. We looked at the care records for five people who used the service, medicines records for 15 people and recruitment records for five staff.

Updated 30 March 2016

The inspection took place on 26 January 2016 and 1 February 2016 and was unannounced. We last inspected the home 18 May 2015 and found the registered provider met the regulations we inspected against.

Thornbury Care Centre is registered to provide nursing or personal care for up to 44 people. At the time of our inspection there were 35 people living at the home, some of whom were living with a dementia.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission 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.

The registered provider had breached regulations 9 and 17 of the Health and Social Care Act 2008. This was because people’s care plans did not reflect their current needs and preferences. Care for people living with dementia needed to be improved. In particular, meaningful engagement for people to help reduce the level of behaviours that challenged. Actions and improvements identified during quality assurance audits were not completed in a timely manner.

You can see what action we told the provider to take at the back of the full version of the report.

Most people and family members were happy with the care provided at the home. People said they were treated with dignity and respect from kind and caring staff. One person said, “They look after me okay.” Another person said, “They look after me well.” One family member said, “Looks fine to us. [My relative] is always looked after well. I have never seen anything to bother us.”

People told us they were safe living at Thornbury Care Centre. One person said, “I feel safe enough, [there is] nothing to worry us.”

Staff had a good understanding of safeguarding adults and the registered provider’s whistle blowing procedure. They also knew how to report concerns. One staff member said, “I have not needed to use it [whistle blowing procedure]. If I needed to I would definitely use it.”

Medicines records were usually completed accurately. There were a small number of gaps in signatures on medicines administration records (MARs). Medicines were stored safely and securely.

We received mixed views from people and family members about whether there were sufficient staff on duty. People said there were enough staff but some family members said there weren’t enough. All of the staff we spoke with felt staffing levels were appropriate to meet people’s needs.

Staff were recruited in line with the registered provider’s recruitment and selection procedures.

We observed a significant number of people did not have access to their ‘buzzer’ to allow them to call for help if needed.

Environmental improvements were on-going. One family member said, “They have improved it. It is clearly on-going. They could do with brightening up the paintwork.”

Regular health and safety checks were carried out to help keep people safe. This included checks of fire safety and equipment staff used to support people.

Accidents and incidents were logged regularly and action had been taken to help prevent the situation happening again.

All staff members told us they were well supported. One staff member said, “Anything you go to Diane [registered manager] with is really dealt with. Diane has been totally supportive.”

The registered provider followed the requirements of the Mental Capacity Act 2005 (MCA). Deprivation of Liberty Safeguards (DoLS) authorisations were in place for relevant people. Staff knew how to support people with decision making and understood the importance of gaining people’s consent before providing care. Formal consent within care records was inconsistent, as some people who were able to had not signed their care plans and other documents.

Most people we spoke with said they were happy with their meals. Although people generally experienced a pleasant lunchtime, people in the downstairs dining room waited a long time before served their meal. Staff ensured people were offered choices, such as a choice of drinks and meals.

People were supported to access the healthcare they needed. One person commented, “I see my doctor if I need to.” Care records evidenced regular input from a range of health professionals.

Although people said there were opportunities to take part in activities, some activities advertised for the day of our inspection did not take place.

Some family members felt communication with the home could be improved. People and family members had opportunities to give their views about the care provided at the home. Regular meetings were held and family members had given mostly positive feedback following consultation in December 2015.

Family members said they could visit the home anytime. One family member said, “We can come when we want.” Staff described the home as having a good atmosphere. One staff member told us, “I have always said it is a really friendly home.”

Staff had opportunities to give their views about the home, through questionnaires and regular staff meetings.

Significant events were monitored to identify trends, including accidents, incidents, hospital, admissions, weight loss and pressure sores.