Thornhill Nursing 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 remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of legal regulation in relation to good governance at the service.

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Some staff demonstrated an understanding of the provider’s vision to deliver personalised care to people. However, staff reported that ongoing staffing challenges frequently hindered their ability to consistently meet this expectation. Staff reported mixed messages and a lack of clear guidance from leadership, contributing to confusion about priorities and standards of care. Feedback from people using the service indicated that their individual preferences were not always known or respected, reflecting a disconnect between the provider’s stated vision and actual practice.

Additionally, we found that inconsistent management oversight had negatively impacted the overall quality of care provided to people. This lack of consistent leadership has contributed to variability in how the provider’s vision and values are translated into day-to-day practice.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Whilst managers and leaders were passionate, there was an absence of consistent leadership within the service. Staff reported concerns regarding the quality of support they were receiving, indicating a lack of effective management presence and oversight. Quality assurance processes were not consistently implemented, and the delegation of responsibilities was unclear, resulting in a lack of clarity about who held responsibility and accountability for key areas of the service.

During the inspection visits, managers in charge demonstrated limited knowledge of the individuals using the service and their specific needs. For example, managers were not aware of who was cared for solely in bed, who required regular repositioning, who had pressure wounds, who had lost weight recently. This gap in understanding impeded their ability to provide compassionate, person-centred leadership and effective oversight. This lack of capable leadership contributed to uncertainty among staff, ineffective quality monitoring, and a decline in the overall standard of care.

People did not feel they could speak up and that their voice would be heard. Staff did not consistently feel confident in raising concerns, despite being aware of the provider’s whistleblowing policies. This lack of confidence was evident through discussions with staff and review of staff meeting minutes, which showed minimal staff input and engagement. Leaders demonstrated limited awareness of staff perceptions regarding job security and their views of the CQC, influenced by previous communication from management.

Several staff members expressed a lack of trust and confidence in the leadership and senior management team. However, the provider had held meetings aimed at engaging staff and seeking their feedback, though these efforts had not fully addressed underlying concerns or improved staff openness. This indicated a need to further develop a culture where staff feel safe and supported to speak up without fear of reprisal.

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 have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Since the previous inspection, there has been a notable lack of oversight and effective management of governance systems and processes. Leadership had been inconsistent, resulting in the failure to complete essential quality audits and reviews necessary to drive and sustain improvements within the service.

The most recent provider audit shared was dated January 2025, which identified several issues that were identified and remained unaddressed at the time of this inspection. Medication audits also revealed shortfalls, some of which had not been rectified for up to 3 months. This indicated delays in responding to known risks and concerns.

Furthermore, key quality assurance processes had not been implemented, undermining effective oversight of critical aspects of care. For example, there was a lack of structured monitoring and review relating to weight loss management, repositioning schedules, food intake, mealtime observations, and staff competency assessments.

These gaps in governance and management oversight contributed to missed opportunities to identify, escalate, and resolve care and safety concerns promptly, impacting the overall quality and safety of the service.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. Resident meetings had been held, providing an opportunity for people using the service to share their views and raise concerns. However, despite these meetings, people were not consistently involved in reviewing or shaping their own care plans. This limited their ability to influence decisions about their care and support, which is essential for person-centred care and positive outcomes.

The provider had established processes to promote partnership working with external health and social care professionals, recognising the importance of collaborative working to meet people’s complex needs. Nevertheless, these partnerships were not always effectively implemented, as evidenced by gaps in communication and coordination with professionals. Despite this, people and relatives told us they felt they would be able to receive visits from the relevant professionals should they need additional support.

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

Significant improvements were required to ensure continuous learning and to achieve consistently good quality of life and outcomes for people using the service. This need for improvement has been acknowledged by managers and the senior leadership team. However, since the last inspection, progress has been minimal. The action plan submitted by the provider indicated that many areas of concern had been addressed and completed. Nevertheless, the inspection findings did not support this assertion, with many issues remaining unresolved at the time of our visit.

There was no evidence of learning from deaths or incidents within the service, and no demonstrable focus on improving equity, outcomes for people, or enhancing quality of life. Systems and processes to support quality compliance and continuous improvement were not effectively established or embedded.

Furthermore, there was insufficient evidence of effective sharing of wider lessons learned across the provider group. This limited the service’s ability to drive meaningful and sustained improvements in the quality of care.