Thornton House Residential Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. Although we were assured the service was well-led and leaders and the culture they created promoted high-quality, person-centred care, some issues in care standards remained and the service was currently without a registered manager. Further time was required to fully evidence the embedment and sustainability of improved practices.

This service scored 61 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The service was experiencing significant changes in its leadership at the time of our inspection, for example, the registered manager had left the service, and the new manager had not yet commenced with the service.

Although the former registered manager was highly thought of by staff, they had only returned to the service on a temporary basis to provide support until the new manager started. There was a deputy manager in place who was new to the home. Further time was therefore required for a shared strategy and vision to develop and a positive culture to embed.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Although the former registered manager demonstrated a passion for the work they did, some issues identified at the last inspection had not been fully resolved. Some of the shortfalls we identified, had not been fully highlighted by the leadership team in their governance tools.

Further time was also required for the deputy manager to gain the knowledge, skills and experience to help assist with the leadership and management of the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Systems and processes enabled people, relatives and staff to express their views, including meetings and surveys.

However, we observed there was no regularity of meetings, including meetings for staff and people. We spoke to the manager about this who confirmed plans were in place to hold meetings on more regular basis.

People and family members told us there were opportunities to provide feedback and felt comfortable raising any issues and believed staff and managers would listen and respond. A relative told us, “I’ve not been invited to a meeting yet, but if I had any concerns, I would raise them right away.”

Staff were also able to voice their opinions and views in a variety of both formal and informal ways. One member of staff told us, “I would feel comfortable to raise any concerns that I had.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Equality and diversity were actively promoted, and processes were in place to help ensure staff felt treated equitably.

Staff told us they felt respected, valued and supported.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

Although governance processes were in place, some residual issues remained from the last inspection. Governance processes had not always been effective in identifying the issues we found at this inspection. These included inconsistencies in care plans, shortfalls in daily care recording, safe medicines management and issues with the environment, such as the cleanliness of the kitchen.

However, the provider had made a great deal of progress since the last inspection and had made improvements to meet the breaches of regulation. Whilst this hard work was recognised, further time was needed to further develop and embed the improved practices to ensure care was consistently delivered in a safe and high-quality way.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider was open and collaborative with relevant stakeholders. It worked in partnership to help support care provision and joined up care. We saw examples of the provider working in partnership with external professionals to help ensure people experienced a more seamless experience of care and support.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Quality assurance arrangements were in place to help identify any areas for improvement but had not always been effective at identifying shortfalls we identified. Although leaders considered information about the service’s performance and how it could be used to make the required improvements, further time was needed to permit the improvements to take shape and embed.

However, the provider demonstrated a commitment to improving, they acted on any feedback provided during the inspection in a positive and proactive way.