Thornhill Nursing Home

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.

At our last assessment we rated this key question Inadequate. At this assessment the rating has remained Inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation in relation to safe care and treatment, safeguarding people from avoidable harm or abuse and safe staffing.

This service scored 38 (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.

The provider had not been consistent in the application of safe systems and pathways processes.

We found staff did not always keep clear records on incidents and safety events at the service. This can impact the ability for visiting health and social care professionals to review records to understand people’s needs. For example, 1 persons’ care plan had not been updated following hospital admissions and involvement from multiple healthcare professionals. A General Practitioner (GP) had discontinued certain medications for this person and advised staff to monitor for specific symptoms. Despite care plan reviews occurring after this advice was given, the relevant information had not been accurately reflected or updated within the care records, limiting staff access to current and essential guidance.

The provider did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

One person was observed to be in distress, expressing this in a way that repeatedly placed themselves and others in the service at risk of harm. We saw staff did not intervene to understand and de-escalate the persons distress or reassure other people. People and staff told us this was a regular occurrence; however we found they had not recorded previous incidents. This lack of recording would impact the provider’s ability to identify and act on the risk of abuse to others. It would also impact local safeguarding teams from investigating these incidents.

We saw that staff had recorded unexplained bruising on some people. However, managers were unaware of these injuries and had not undertaken investigations to determine their cause. Furthermore, no safeguarding referrals had been made to the local authority safeguarding team to alert them of these unexplained injuries. This would impact an external investigation occurring. This risked people continuing to receive injuries that may be preventable.

We found that staff had received safeguarding training and managers were able to explain the principles of good safeguarding. However, we were not assured that good practice was being followed. As incidents that may be considered abusive, had not been acted on appropriately. Following the inspection, the provider informed us that updated training and processes would be arranged.

Some people at the service were under regular supervision and control, as they were unable to consent to the care provided. This had been legally authorised under Deprivation Liberty Safeguards (DoLs). However, the authorisations included specific conditions that the provider needed to comply with. The staff were unaware of any conditions in place, and the provider was unable to demonstrate how conditions were being met. This meant these people’s restrictions may not have been provided in the least restrictive way and in their best interests. Some people at the service used technology that would monitor their movement (like pressure sensor matts that called staff support when activated).Before putting these in place, the provider had assessed people’s ability to make decisions about this equipment, and where they were unable to make a decision, they had only used the equipment in line with the persons best interests. This followed the principles of the Mental Capacity Act (2005).

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe.

Although most people and relatives told us they felt safe in the service we found a series of shortfalls in the safe management of risk. Some people at the service needed staff support to regularly reposition, this was to prevent pressure related skin damage. However, we found staff did not always record when 3 people were supported to reposition. This meant we were not assured that these people were supported in line with their planned care needs. If people are not supported to reposition as planned, there is an increased risk of developing pressure injuries. Additionally, records showed 4 individuals had experienced a weight loss exceeding 2 kilograms within 1 month; however, no actions were taken to address this decline in nutritional status, increase their nutritional intake, or involve relevant healthcare professionals. As a result, these individuals were at heightened risk of malnutrition and associated adverse health outcomes.

Furthermore, where risk assessments were in place, they lacked sufficient detail and clear guidance to enable staff to effectively mitigate identified risks. For example, the risk assessments did not detail the assessed risk, what actions staff needed to take to minimise the risk and failed to detail any outcomes. Thereby, increasing the potential for avoidable harm.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Some environmental improvements had been made since the previous assessment. Broken windowpanes had been repaired, the laundry and kitchen areas had been remodelled, and maintenance issues such as broken baths had been addressed. However, further improvement was required, l to ensure ongoing safety and suitability.

We identified areas of the home that were not being maintained in a safe condition. For example, the kitchen door on the first floor was not lockable, posing a potential risk to individuals who may access the area unsupervised, including exposure to hot surfaces, sharp utensils, or hazardous substances. Several bedrooms remained unidentifiable, as they lacked names or numbers on the doors. This not only limits orientation for people living in the service but could also impede emergency response in the event of a fire or other critical incident. We also reviewed personal emergency evacuation plans (PEEPs) and found they lacked sufficient detail. In particular, the plans did not clearly specify the equipment required to support individuals with mobility needs during an emergency, reducing their effectiveness in guiding staff during an evacuation.

The provider was responsive to the environmental concerns we found during day 1 and 2 of assessment and some of these issues were addressed by day 3 of the inspection.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development to provide safe care that met people’s individual needs. There was an inconsistent understanding among staff regarding the expected staffing levels during day shifts. This lack of clarity resulted in occasions where shifts were understaffed, as confirmed by a review of rota records and conversations held with staff members. Additionally, there was a significant reliance on agency staff to cover shifts. On 1 occasion, only 1 permanent member of staff was on duty, with the remaining 7 staff members being from an agency. Despite being aware of this, management failed to provide effective leadership, oversight, or support to staff during this shift.

There was also no clear induction, guidance, or support in place for new agency staff. On days 1 and 2 of the inspection, we spoke with several agency workers who reported having worked only 1 prior shift at the service. They informed us they had not received introductions, support, or time to familiarise themselves with individuals’ care plans prior to commencing duties.Staff training compliance was low, with many staff members having not completed up-to-date training in both mandatory and supplementary subjects. This presented a risk to the consistent and safe delivery of care.

However, a review of recruitment records for 3 staff members confirmed that the provider had followed safe recruitment procedures.

The provider did not always assess or manage the risk of infection. Several staff members were not adhering to 'bare below the elbow' protocols, for example we observed they were wearing jewellery and watches, failing to comply with infection prevention and control (IPC) procedures. Hand sanitiser was not consistently available in some areas of the home, with dispensers not being restocked, limiting opportunities for effective hand hygiene. Although IPC audits had been completed within the service, they failed to identify or address a number of the shortfalls observed during the inspection therefore we could not be assured the provider’s quality assurance process in monitoring and maintaining IPC standards was effective.

However, we did observe staff wearing appropriate personal protective equipment (PPE) during routine care activities and meal preparation. Improvements in IPC practice were noted by the third day of the inspection, with enhanced compliance from staff and improvements in the overall cleanliness of the environment. These changes followed initial feedback provided during the inspection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found that protocols for the administration of ‘as required’ (PRN) medication, where in place, lacked detail and were not person-centred. As a result, they did not provide staff with adequate guidance on how to assess and monitor the need for such medication. The application of topical medicines, such as prescribed creams, was not consistently recorded, and some administration instructions were vague. This lack of clarity and documentation meant there was no assurance that topical treatments were being applied safely and in accordance with prescribed requirements.

During our review of patch rotation records, we found that the provider had not implemented a system for recording the specific sites where pain relief patches were applied. This omission meant the provider was unable to evidence compliance with prescriber and manufacturer guidance, thereby placing individuals at risk of adverse skin reactions due to potential incorrect application or site rotation.

Some people were at risk of choking, so they needed their drinks thickened with a prescribed powder to reduce the risk. Staff did not consistently record when this prescribed thickening powder was used. We were therefore not assured that is was used as prescribed.

However, medication storage was found to be safe, with appropriate temperature monitoring in place and adhered to. Stock levels were checked regularly, and we observed medication administration being carried out with kindness, patience, and respect for the individuals receiving care.