Thorndene Residential Care 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 requires improvement. At this assessment the rating has remained 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 provider was in breach of legal regulation in relation to safe care and treatment.

This service scored 50 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Lessons learned were not evidenced and incident analysis was not completed fully. There were no actions as a result of incidents. For example, the weight audit gave no overview of weight loss concerns and did not identify any action required to address the concerns. This was amended following our inspection, and the management team commenced a lessons learned process. However new systems required embedding into practice.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. The electronic care planning system could generate information to be used when people transferred between services. However, care plans were not always up to date so did not always reflect people’s current needs.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, and free from avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. A safeguarding record was in place but there was no overview of open safeguarding concerns. Deprivation of Liberty Safeguards [DoLS] had been applied for but there was no overview for when existing DoLS were due to expire. People told us they felt safe living at the home. One person said, “Oh yes, we’re safe, no problem.” Another person said, “I’m happy to be here [Thorndene].”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks associated with people's care were not always identified and managed to keep people safe. One person had recently moved into the home but had no care plans or risk assessments in place. This person had been identified as a risk of falling, but no care plan or risk assessment was in place to support this.

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. The provider could not always evidence that routine maintenance, and checks had been carried out in a timely way. We observed areas of the home where light bulbs were out and had not been replaced. This made some areas dark. One person’s wheelchair was in use and the tyres were flat and required attention. There was no record of checks being carried out to ensure equipment such as wheelchairs were maintained appropriately. One dining table had to be removed on the day of our site visit as we found this was unsafe.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Not all staff had accessed all the appropriate training courses. For example, only 60% of staff had completed bedrails assessment and management, and only 70% of staff had completed training regarding diet and nutrition. Staff recruitment files are not well organised. Information was not easily accessible in the files and some pre-employment information was missing. Some people told us there were not enough staff to respond to their needs. One person said, “No [not enough staff] not for how many there are of us now,” explaining the number of residents had recently increased.

The provider did not always assess or manage the risk of infection. We carried out a tour of the home and found areas that were worn and not easy to keep clean. The provider told us there was a refurbishment plan in place to address these concerns.

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. At our last assessment we found protocols in place to manage medicines prescribed on an ‘as and when’ required basis, were not detailed enough. At this assessment we found no improvements had been made. We also found handwritten entries on the medication administration records, were not double signed, therefore no check that medication had been documented correctly. Where people were prescribed patches, there was no clear record for rotation of patches.