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 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 requires improvement. At this assessment the rating has changed to inadequate. 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 in breach of legal regulation in relation to the governance of the service.

This service scored 36 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. The Service had 2 managers who were in the process of registering with CQC. They were new to the management role and required support from the provider to ensure management systems and processes were effective.

People did not always feel they could speak up and that their voice would be heard. People and relatives told us issues they had raised either took a while to be resolved or a resolution was not found. Staff told us they had access to a whistle blowing process and us they would raise concerns if they needed 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. 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. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Management team were not organised and did not have information readily available. Audits needed to be more streamlined to ensure the management team have a good overview of the service. Audits in place did not identify the concerns we found during the assessment around medicine management, risks, and management of the home. Systems and processes had not improved since our last assessment.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. We saw people's care plans included referrals to healthcare professionals as and when required. The management team felt the service worked well with external professionals. However, advice from healthcare professionals was not always documented to evidence staff had followed their guidance.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. At our last inspection the management team had made enough improvements to meet the breaches from the previous inspection about safe care and treatment and good governance. At this inspection the provider had not sustained the improvements and showed they had declined in some areas which led to us raising concerns regarding safe care and treatment and good governance again.