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 changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was no longer in breach of legal regulation in relation to good governance.

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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had made improvements since the last assessment and there was an open and positive culture amongst the team. The vision and values were shared, with a focus on supporting people, sustaining improvements and making further progress with regards to quality of care. Staff were happy in their role. Comments included, “We have improved lots of areas. I give [people living here] my best as I would my own family. They are family to me, and I look after them as if they are” and “Things are better now, improved. Everyone knows what they are doing.”

The provider did not consistently have skilled and inclusive leaders in place, 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. There had been ongoing concerns with continuity and stable leadership at the service during, and since the last assessment. The high turnover of managers had impacted quality and continuity of care. Provider level oversight during this time failed to fully address all concerns identified by CQC during the previous 2 assessments. However, the provider had recently appointed a new manager who started in October 2025. The manager showed good knowledge and skill. They had developed relationships with staff and people and had positively impacted the service. Comments included, “The manager is so welcoming,” “I like the manager. She is always helping, every step, if I need guidance and support, she does everything,” “The new manager works better with staff” and “The manager we have recently, she is still new for us and the [service] but generally she is doing alright there is no concern.” More time was required to further embed the management changes and stabilise leadership at the service.

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

Staff felt able to speak up and discuss concerns and ideas with the manager. They felt their voice would be heard. Feedback included, “Now when I raise an issue, I will always get a response and there is a bit more care,” “I would be able to tell the manager [if I had concerns], I would always talk to the manager” and “If I have an issue I can raise it and feel supported.” People and relatives also felt able to raise concerns should they need to.

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.

The provider employed a diverse workforce from varying backgrounds and cultures. Staff felt they were treated equally and spoke positively about their role and employment. One staff member told us, “I am definitely treated equally and fairly.” The provider supported flexible working.

The provider needed to demonstrate further embedding of responsibilities, roles, systems of accountability and good governance.

Since the last assessment the provider had made improvements at the service, and they were no longer in breach of legal regulation. Governance systems and processes were in place and were effective in supporting some areas of service improvement. However, during the assessment we continued to find concerns that had either not been identified or fully addressed. For example, record keeping and security of confidential information; environmental security; PEEPs; supervision and appraisal; and medicines management. Some areas requiring further improvement had been identified during the previous 2 assessments, such as management of medicines, yet had not been fully rectified. However, the provider and manager had appropriate quality assurance tools in place that would support ongoing improvement. They were committed to ongoing service development, which was demonstrated during the assessment process with timely responses to some of the concerns identified.

The provider understood their duty to collaborate and work in partnership to drive improvements. There was evidence of partnership working with the local authority. However, not all areas requiring improvement were addressed in a timely manner. The previous assessment completed by CQC identified repeated concerns which had still not been fully addressed during this assessment. In addition, people’s care records were not always updated following incidents of a safeguarding nature. Therefore, collaboration was not always fully effective to ensure services worked seamlessly for people.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

There was clear evidence of improvements made by the provider as all 6 previous regulatory breaches had been met. However, some improvements were still being implemented and other improvements still needed to be put in place. The provider was working towards addressing the outstanding concerns.