Thimbleby Court

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. This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a positive approach to learning to improve safety. Staff described a culture where they could raise concerns and contribute to improvements in practice. They told us managers were approachable and responsive, and that when issues were identified, action was taken to address them. This included senior staff being visible in practice and providing direct support during periods of pressure to ensure safe care was maintained.

People and relatives had opportunities to share feedback about their experiences, including aspects relating to safety. They told us they could speak to a range of staff and that suggestions were listened to. Records showed meetings were held and information was shared, with people able to raise ideas to influence improvements.

Staff were supported through training and ongoing learning to carry out their roles safely. They described being able to access additional support where needed and demonstrated the ability to reflect on their practice and adapt their approach to reduce risks.

There were well-established systems and pathways in place to support continuity of care and partnership working with external professionals. The service worked closely with healthcare professionals, meeting regularly to review people’s needs and coordinate care. Professionals described this approach as organised and proactive, with the service taking an active role in identifying people who required review and ensuring appropriate referrals were made.

Communication between staff and healthcare professionals was effective. Staff were proactive in escalating concerns and sharing information about changes in people’s health, enabling timely input and intervention. Professionals reported that staff made prompt contact to seek advice and maintained good oversight of people whose needs were changing or deteriorating.

Staff followed through on guidance from external professionals, supporting continuity between assessments, recommendations and day-to-day care. Staff implemented care and rehabilitation plans and worked consistently to support people in line with professional input. This included ongoing monitoring and adapting support as people’s needs changed.

There were effective systems in place to safeguard people from the risk of abuse. People and their relatives consistently told us they felt safe living at the service. One person said, “I feel absolutely safe. It’s the way it’s run and no one can get in who shouldn’t be here,” while another described, “It’s a good substitute for home. There’s always someone there.”

People and relatives knew who to speak to if they had a safety concern and described a range of accessible staff. Family members said, “I would speak to the receptionist. [They would] guide me to the right person,” Another relative said, “I would speak to the manager” and “Anyone, [they] all are approachable.” This showed there were clear and understood routes for raising concerns and that staff were visible and accessible.

Most relatives told us they had not needed to raise concerns. Where concerns had been raised, these were generally addressed, although there were isolated comments where people felt responses could have been clearer or more consistent, such as in relation to missing belongings or communication. These concerns did not indicate widespread safeguarding issues but highlighted areas where consistency could be strengthened.

Staff demonstrated an understanding of safeguarding responsibilities. They were aware of how to recognise and escalate concerns and described clear processes for reporting issues to senior staff. Staff told us they felt confident to raise concerns and described staff as approachable and responsive.

Deprivation of Liberty Safeguards (DoLS) applications were made appropriately where required, and authorisations were in place to ensure any restrictions were lawful and in people’s best interests.

People were involved in understanding and managing risks, although this was not always supported by clear and consistent guidance. Care plans did not always include clear, detailed information to guide staff on how to recognise and respond to distress. There was limited guidance on specific strategies, including when approaches such as the use of medicines may be required. This meant staff relied on their own experience and knowledge, which did not support a consistent approach.

Care documentation did not always reflect current best practice in terminology. For example, language such as ‘challenging behaviour’ was used, which did not align with a person-centred approach or the service’s dementia framework. This reduced clarity around underlying causes of distress and how staff should respond safely. Following our inspection, the provider took steps to address these concerns. References to ‘challenging behaviour’ were removed from care plans and updated to include clearer, person-centred guidance on recognising and responding to expressions of distress. Additional guidance was introduced, and staff were encouraged to record strategies that had been effective to support a more consistent approach to care.

People and relatives told us staff understood their needs and supported them safely. Staff were described as confident and competent, with examples of supporting people to manage risks while maintaining independence. A relative told us, “Yes, [staff] have the training. A couple of residents were upset, and the carers were lovely with them. The same with my relatives, [staff are] patient.”

Risks to people’s health and wellbeing were identified and managed with involvement from people and those close to them. Relatives described being included in decisions about care, with staff seeking advice from external professionals and adapting support accordingly.

The service provided an environment that supported people to receive care safely. The building was suitable for the needs of people using the service. Bedrooms were spacious, with wide doorways and accessible bathrooms to support mobility and independence. People had access to a range of communal areas, as well as quieter spaces and outdoor areas which contributed to their comfort and wellbeing. A relative told us, “I think [the home] is clean and modern, more like a hotel. Fresh looking. Excellent amenities.”

There were effective systems in place to ensure the safety of the premises. Appropriate checks and maintenance were carried out, including fire safety and other health and safety requirements, to ensure the environment remained safe. The maintenance staff took a proactive approach to engaging with people, speaking with them directly to check if anything required repair or adjustment. This included asking people if they needed items fixing or support with personalising their space, ensuring maintenance needs were identified and addressed promptly.

Fire safety arrangements were well organised, with regular checks and testing of equipment, alongside staff training and drills to ensure staff understood their roles in an emergency. However, Personal Emergency Evacuation Plans (PEEPs) required further review to ensure they fully reflected people’s individual needs and provided clear guidance for staff. The lack of detail could impact the consistency and effectiveness of responses in the event of an emergency.

There were sufficient numbers of staff deployed to meet people’s needs safely. Observations during the inspection showed staff were visible within communal areas and available to support people when required. In addition to care staff, the service had introduced a hospitality role, which added flexibility across the home. This role supported people with day-to-day needs and provided additional opportunities for meaningful interaction, such as spending time talking with people and identifying when someone may require assistance.

People and relatives were generally positive about staff and the care they received. Feedback indicated staff were kind and understood people’s needs well. One relative said, “The carers are confident and competent, [and] know what they are doing,” which reflected wider feedback about staff approach and attitude. Staff received training appropriate to their roles, including training in supporting people living with dementia. This supported staff to understand people’s needs and communicate effectively, helping to promote people’s wellbeing and experience. There were safe recruitment practices in place. Relevant pre-employment checks were completed to help ensure staff were suitable to work with people using the service.

There were effective systems in place to prevent and reduce the risk of infection. People and relatives consistently described the service as clean and hygienic. Comments included, “Exceptionally clean,” “Spotlessly clean”, “Very clean” and “It is spotless. Wherever you go, it is immaculate.” Observations supported this, with communal areas and bedrooms maintained to a high standard.

People were supported to maintain their personal hygiene in line with their needs, with staff providing assistance where required. Staff followed infection prevention and control practices and used personal protective equipment (PPE) appropriately. Relatives told us, “They wear aprons and gloves”, “Yes, [staff] wear PPE” and “Yes, [staff are] on the ball when it comes to infection control.” This demonstrated staff understood and followed safe hygiene practices in line with people’s needs.

Food preparation areas were well maintained, and kitchen practices supported good hygiene. There were appropriate arrangements in place for the safe handling and preparation of food, and kitchen staff were aware of people’s dietary needs and how to prepare food safely.

People were supported to access vaccinations and receive appropriate healthcare, and relatives told us they were kept informed and involved where needed.

Medicines were stored safely and managed in line with expected standards. Clinic rooms used to store medicines and associated equipment were well maintained and free from clutter. Medicines were stored in line with manufacturer recommendations and temperature monitoring was in place, with daily checks completed.

Staff followed clear processes to ensure medicines were available when required. Stock was replenished appropriately and electronic systems supported accurate monitoring of balances, which were maintained correctly.

Medicines subject to additional controls due to the risk of misuse or abuse were managed safely, with appropriate storage, monitoring and clear compliant records in place. Homely remedies were available and administered in line with policy. This included ensuring appropriate authorisation was obtained from the primary care team and staff competency was assessed before administration.

Medicine administration records (MARs) contained key information, including when people had allergies. Medicines were administered as prescribed and staff used care plan information to support safe practice. Protocols were in place for ‘when required’ (PRN) medicines to guide staff on safe administration and body maps were used effectively to support the application of creams and patches. Care plans included medicine-specific information, such as monitoring requirements and risks associated with storage and administration.

Regular audits were completed to monitor medicines management, and action was taken to address any issues identified.