Thorndene Residential Care 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.

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 which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. However, not all staff we spoke with knew what the provider’s values were or what improvements were still required within the home. Some people and relatives we spoke with were unclear about what actions were taken following concerns being raised. Provider values required embedding into practice.

Leaders understood the context in which the provider delivered care, treatment and support. However, they did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. At our last assessment we found the management team were disorganised and did not have information readily available. At this assessment we found the management team were much more confident and organised. However, they required support from the provider to ensure management systems and processes were effective.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistle blowing policy in place and staff felt supported to raise concerns

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. Policies and procedures were in place to support staff and to ensure they were happy at work. Staff had access to a staff handbook and training policy. The provider had a flexible working arrangement policy. Systems were in place to support staff out of office hours and at a weekend. Members of the management team were on call to support staff if required.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Since our last assessment governance systems had improved and were starting to identify areas of improvement. Audits were more streamlined and more effective in identifying concerns. However, governance systems and processes required embedding in to practice to ensure their efficacy. For example, the environmental audit had failed to identify that large items of furniture were not securely fastened to the wall. The medicines audit had failed to identify the issues we found regarding patch rotation.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The service worked with partners to ensure people received better outcomes. People had access to local clinical services to help ensure they had the right care to meet their needs. We saw people's care plans included referrals to healthcare professionals as and when required.

The provider had improved their focus on continuous learning, innovation and improvement across the organisation and local system. They had started to encourage creative ways of delivering equality of experience, outcome and quality of life for people. They were beginning to contribute to safe, effective practice and research. At our last assessment we rated the service requires improvement with an inadequate rating in the well led section. The provider was working with a consultancy company to drive improvements. Whilst the provider had taken action to address the concerns and were compliant with the previous breaches of regulation, new systems and processes required fully implementing, embedding and maintaining.