Thornhill Nursing Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The provider was in legal breach of regulation in relation to promoting person centred care.

This service scored 36 (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 have a proactive culture of safety which meant lessons were not learnt to continually identify and embed good practice. Safety events, including behaviours that challenge staff and unsafe manual handling of people, were not consistently reported or recorded by staff. This was due to a lack of understanding and awareness of what a reportable safety event is.

As a result of staff not recording incidents, these incidents were not subject to any formal analysis or review, and associated risks remained unmitigated. There was no evidence of lessons learned or improvements arising from these unreported incidents. This risked incidents re-occuring, which left people at risk of harm.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

During the inspection, we observed multiple instances where staff appeared uncertain or lacked the necessary competence to meet the needs of people on the dementia care unit and nursing unit. For example, 1 person who displayed behaviours that challenged may have required enhanced supervision or one-to-one support. This had not been identified or reviewed as a potential increased need prior to the inspection, and there was no evidence of reassessment or multidisciplinary input. Staff also expressed that they did not feel confident or adequately equipped to work in these specialist care areas. The lack of competence impacted not only the quality of care provided but also staff wellbeing.

The provider did not have a proactive culture of safety which meant lessons were not learnt to continually identify and embed good practice. Safety events, including behaviours that challenge staff and unsafe manual handling of people, were not consistently reported or recorded by staff. This was due to a lack of understanding and awareness of what a reportable safety event is.

As a result of staff not recording incidents, these incidents were not subject to any formal analysis or review, and associated risks remained unmitigated. There was no evidence of lessons learned or improvements arising from these unreported incidents. This risked incidents re-occuring, which left people at risk of harm.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not involve people in decisions about their care or tell them what had changed as a result.

Food and mealtime surveys completed in January 2025 highlighted widespread dissatisfaction among people using the service. Feedback indicated a lack of choice and poor food quality, with recurring themes such as: “never asked for my choice,” “no options,” “it’s eat or have nothing,” “staff don’t know my preferences,” “never know what I’m going to get,” and “meals are rushed and portions unsuitable.” Despite the volume and consistency of these concerns, there was no evidence of systematic analysis, and no resulting action plan to address the issues raised. During the first 2 days of the inspection, we observed continued concerns around the mealtime experience and food provision, indicating that feedback had not been used to drive improvements. This meant people continued to receive food that did not reflect their preferences, needs, or expectations, which negatively impacted their dining experience and quality of life.

While relative meetings had taken place, these appeared to focus largely on activities, and there was no recorded evidence of meaningful follow-up or change resulting from feedback. Similarly, although regular staff meetings were held, minutes showed no documentation of staff contributions or views. This limited opportunities for staff to influence service development or raise concerns constructively. 

The provider did not have a proactive culture of safety which meant lessons were not learnt to continually identify and embed good practice. Safety events, including behaviours that challenge staff and unsafe manual handling of people, were not consistently reported or recorded by staff. This was due to a lack of understanding and awareness of what a reportable safety event is.

As a result of staff not recording incidents, these incidents were not subject to any formal analysis or review, and associated risks remained unmitigated. There was no evidence of lessons learned or improvements arising from these unreported incidents. This risked incidents re-occuring, which left people at risk of harm.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this. Not all people using the service experienced the same quality or consistency of care. Although staff had received training in dementia care, people with protected characteristics, particularly those living with dementia or complex behavioural needs did not consistently receive equitable care outcomes. This was due to staff lacking confidence and competence in managing behaviours that challenge and failing to apply appropriate redirection or de-escalation techniques. As a result, some people were not supported in a way that met their individual needs or protected their dignity and wellbeing.

People using the nursing care service were also affected. We found individuals with assessed care needs who were not supported to express or communicate their preferences and were not consistently provided with the care and interventions identified in their plans. This lack of personalised, needs-led care disproportionately impacted those who were less able to advocate for themselves.

This shortfall in equitable care provision placed people at risk of poorer experiences and outcomes and indicated that the provider had not embedded an approach that consistently promoted fairness, inclusion, and responsiveness to individual needs.

The provider did not have a proactive culture of safety which meant lessons were not learnt to continually identify and embed good practice. Safety events, including behaviours that challenge staff and unsafe manual handling of people, were not consistently reported or recorded by staff. This was due to a lack of understanding and awareness of what a reportable safety event is.

As a result of staff not recording incidents, these incidents were not subject to any formal analysis or review, and associated risks remained unmitigated. There was no evidence of lessons learned or improvements arising from these unreported incidents. This risked incidents re-occuring, which left people at risk of harm.