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 changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was no longer 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 53 (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 had made improvements since the last assessment and had built a proactive and positive culture of safety, based on openness and honesty. Incidents were appropriately reported and investigations carried out. However, further improvement was needed with regards to consistently identifying and embedding lessons learnt. Whilst there was some evidence of lessons learnt, these were not consistently identified and, where they were, sufficient action had not always been taken to fully mitigate risks. For example, there had been an incident whereby a person had left the service. During the assessment we found doors leading to areas outside of the service were not always secure. This meant the risk of a person leaving the service unnoticed remained. In addition, there were some gaps in the recording of behaviours that challenge. This meant there were missed opportunities for full analysis and review of such events to learn lessons, mitigate risks and improve.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed. They made sure there was continuity of care, including when people moved between different services.

Improvements had been made since the last assessment. People’s care records were updated when health professionals had been involved in their care and the provider worked in partnership with professionals to effectively support people. However, further improvements were needed with regards to the pre-admission assessment process to ensure all people had accurate and up to date assessments in place prior to moving in. For example, 1 person’s pre-admission assessment was dated 3 months prior to their admission and recommended home care. No updated pre-admission assessment had been completed by the provider. Therefore, we could not be assured that up to date and accurate information was always informing the admission process.

The provider worked with health care partners to safeguard people. However, further improvement was needed to ensure robust documentation and mitigation of risks relating to safeguarding incidents.

The provider had made some improvements since the last assessment and safeguarding concerns were appropriately identified and reported to the relevant agencies. For example, the local authority and CQC. The manager understood their responsibilities with regards to reporting safeguarding concerns and staff had received safeguarding training.However, safeguarding incidents were not always documented in people’s care records. For example, there were 3 people who had been involved in safeguarding incidents, yet the information was not documented within their care plans and risk assessments. This meant there was a lack of guidance in place for staff regarding potential risks and how to keep people safe. The provider took action to rectify this following our feedback.

Staff mostly provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Management of people’s risks had improved since the last assessment. However, there were still some areas where further progress was needed.

Risks to people’s health and safety were mostly, effectively assessed, monitored and mitigated. This included risks associated with skin integrity, falls, nutrition/fluid intake and weight loss. Most people’s care records were detailed and people had care plans in place for their specific health needs. For example, Parkinson’s disease and catheter care. Health care professionals had been involved where needed to ensure risks to people’s health were managed, and people told us they felt safe. However, some people’s records contained inaccuracies and gaps where information needed to be included and/or updated. For example, regarding incidents or a change in health and support needs. In addition, 1 person’s hourly safety checks were not fully complete, and another person’s behaviour forms were not completed in line with their care planned needs. Some people and relatives were involved in reviews of care, but others were not. The provider had a plan in place to address this.

The provider did not always detect and control potential risks in the care environment to support the delivery of safe care.

The provider did not always ensure aspects of the environment were secure to support people’s safety. For example, on the first day of the assessment we found areas that were identified by the provider as needing to be locked, left open and accessible to people. For example, a courtyard door leading to steps and access outside of the service, a sluice area, and a door leading up a steep stairway. In addition, the nursing office was found to be open, with no staff present, there were a number of keys and a lighter stored in the area.

People’s Personal Emergency Evacuation Plans (PEEPs) were not always up to date. Two people had out of date information on their plan and there was a further inaccuracy in the printed file. The provider took action to address this following feedback.

Appropriate health, safety and equipment checks were in place.

There were enough qualified, skilled and experienced staff, who worked together as a team to meet people’s needs. However, improvements were needed to ensure they received effective supervision.

Staff were skilled and showed good knowledge and understanding of the people they supported. They were visible throughout the service, working proactively to meet people’s needs without delay. Staff participated in training and compliance levels were good. However, staff did not always receive regular supervision sessions to support them in their role. Some staff had not participated in a supervision session at all during 2025. In addition, no staff members had participated in an annual appraisal to support their development. This practice was against the provider’s own policy. The manager and provider had a plan in place to address this.

Safe recruitment and induction processes were in place.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Since the last assessment improvements had been made in relation to infection control. The service was clean and tidy. We observed domestic staff cleaning throughout the day. Staff had access to appropriate personal protective equipment (PPE) which they used effectively. The provider had a plan in place to address areas that needed further intervention. For example, stained carpet areas.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Since the last assessment some improvement had been made with regards to some aspects of medicines management. However, further improvements were needed.

Medication administration records (MARs) did not show any missed doses of medication and stock levels were correct. People prescribed medicines to manage Parkinson’s Disease were given these in an appropriate time frame. However, records showed Paracetamol was not always administered in line with prescribed dosing intervals, which can increase the risk of harm.

People prescribed ‘as and when required’ (PRN) medicines had PRN protocols in place. Whilst improvements had been made on these since the last assessment, there were still gaps in protocols for people who were prescribed more than one medicine to treat a specific condition. This could lead to staff being unclear about when each medicine should be administered.

Documentation around bowel records had improved significantly. However, we did note 1 person who did not receive their PRN laxative when they should have received it, which could lead to worsening symptoms.

When medicinal patches were applied to people, the application site was not always documented on the electronic MAR. Patch site rotation is required to minimise the risk of skin irritation. However, since the last inspection, staff had implemented daily checks to ensure the patches were still intact on the skin, and the location site was sometimes documented there.

Creams were still being stored in people’s bedrooms, which could pose a risk to those living with dementia. Body maps were in place on the electronic MAR system so staff could show where these had been applied. However, these were not always completed.

People prescribed thickener, to help with swallowing difficulties, did not always have documentation in their daily care notes to ensure this had been given appropriately and safely. We found an unlabelled tub of thickener in the drug trolley which could pose a risk of being given incorrectly to the wrong person.