14 Thornholme Close

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 good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Systems and processes needed to improve to align with best practice guidance.

We reviewed accident and incident records. The service had reduced the number of incidents from 15 in 2024 to 4 so far in 2025. This represented a significant improvement. A consistent staff team knew people well and had built trust overtime and this had contributed to a reduction in incidents.

However, the incident forms we reviewed lacked the required detail. It was agreed the service would use the ABC model (Antecedent-Behaviour-Consequence) or other similar tools to ensure more detail was captured to support learning in future. This is a framework used to understand and analyse behaviour or people communicating distress. This model is widely used to analysis and to identify triggers, understand behaviour patterns, and to develop effective interventions.

Staff told us they were encouraged to report incidents, and the managers were quick to respond. Debriefs also took place with staff and people when required after incidents. In Positive Behaviour Support (PBS), debriefs are structured discussions held after incidents involving challenging behaviour. They serve as a crucial tool for staff support, learning, and improving PBS plans. Debriefs help understand the incident, identify triggers, and develop strategies for future prevention. The debrief forms we reviewed during the assessment lacked the required detail. It was agreed these would be more detailed in future.

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

A very detailed preadmission assessment was completed to ensure people’s needs were understood and a care plan could be implemented to meet their needs.

The service worked very closely with social workers. The social worker we spoke with was very positive about the close working relationship they had with staff.

People were supported to experience a smooth process when they were referred to other services. Information was shared so they received the care and support they needed, in line with their individual plans.

Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, the provider did not always share concerns quickly and appropriately with all relevant bodies.

Systems for identifying and reporting safeguarding concerns were not always effective. The Care Quality Commission (CQC) had not always been notified of key incidents. These were all submitted during the assessment and measures taken to ensure future compliance. People had not been harmed, and the required actions had been taken by staff after each incident to keep people safe. This is reported on further in the well led domain of this report.

Staff had access to policies and procedures in safeguarding. Staff were supported through their induction and training to understand their safeguarding responsibilities. We discussed safeguarding with 5 staff and checked their learning in practice. They understood their responsibilities and how they should report concerns to the management in the service.

People’s rights were upheld, and staff training included training in the Mental Capacity Act and Equality Diversity training. There was a clear understanding of the Deprivation of Liberty Safeguards (DoLS) and clear processes were in place to monitor DoLS applications. Restrictions were kept to a minimum and best interest decisions were made to support people safely.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were involved and in control of their care. They were regularly consulted and updated about all aspects of their care. People did not report any concerns. Staff told us the care plans were clear and provided guidance on how to manage any risks.

The service focused on the least restrictive approach. The staff worked closely with people to ensure there was a balanced and proportionate approach to risk that supported them and respected the choices they made about their care.

Where appropriate, people were encouraged to take carefully managed risks in order to live more fulfilling lives.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The home had systems in place to check the home environment was safe. This included up to date safety certificates for gas, electric and regular checks of fire safety equipment.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People experienced continuity of care. The service had enough staff, and they did not use agency staff. There was a consistent staff team in place who knew people’s needs well.

Staff received the support they needed to deliver safe care. This included induction, supervision, appraisal and support to develop. Staff were very positive about the support they received. Staff told us, “We were given an induction focused on [resident] as we came here as a team to support [resident]” and “The training has been very good and has helped me a lot. This is my first time working in care. The support given is very good.”

Staff were recruited safely and had the appropriate pre-employment checks in place before employment commenced.

Policies and procedures were in place to manage infection control safely.

Staff were trained and understand their role and responsibilities for maintaining high standards of cleanliness and hygiene in the premises and their own personal hygiene, including hand hygiene. We were offered hand sanitiser on arrival, and we observed staff using it at regular intervals and between different tasks.

Staff used personal protective equipment (PPE) effectively and safely. All relevant staff had completed food hygiene training and followed the correct procedures for preparing and storing food.

The service had effective arrangements for keeping the premises clean. Staff followed regular cleaning schedules and regular audits were in place.

We observed a clean environment during 3 onsite visits and staff were positive about the cleanliness of the environment when asked for feedback.

Medicines were managed safely. People were supported by staff who followed systems and processes to prescribe, administer, record and store medicines safely. Staff who administered medicines had been trained to do so and staff had regular competency checks to ensure procedures were followed.

We requested medicine records with a ‘when required’ dose (PRN) were updated to include all the required information. This was completed during the assessment.