We inspected Thorp house on 9 and 10 January 2019. We returned on 11 January 2019 to give the registered manager feedback and to clarify some of the findings. The first day of the inspection was unannounced. We arrived at 6am on the second day of the inspection so we could talk to night staff and see how people were supported in the early hours of the morning as they were getting up. Thorp House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The home can accommodate up to 41 people. The home supports people with nursing and residential care needs and supports people living with dementia. At the time of the inspection there were 39 people in the home as two were in hospital at that time. The home was full and requests were being received for beds when they became available.
The home was a large extended building set over two floors. There were a number of communal areas on each floor and one corridor from the ground floor led to five self-contained apartments. The main kitchen and laundry facilities were on the ground floor.
The home had a registered manager in place who at the time of the inspection had been registered with the Care Quality Commissions for just over two years. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
The last inspection in January 2018 found the provider in breach of four regulations. The home was found to require improvement overall and in all key questions of safe, effective, caring, responsive and well led. Breaches were found in how the provider managed safeguarding concerns and whistleblowing, how the provider upheld the dignity and respect of people living in the home, how risks were managed and how the provider audited and managed systems to identify concerns and continuously drive improvement.
At this inspection we found action been taken to meet the requirements of the regulations and two of the previously breached regulations were now fully met. We found the provider and all staff at the home were very conscious of upholding people’s dignity and ensured people were respected at all times. We also found all staff had received training in safeguarding and when we spoke with them they displayed a good understanding and knowledge of when and where to report concerns. We found action had been taken to improve how risks were managed but some further action was required. People’s needs were not assessed at point of change and action from the changes was not always evident or easy to find. This regulation remained in breach.
We found the same with the systems and processes in place for auditing and monitoring provision of the service that still required improvement. We found some issues were found in the systems used by the provider and there was still a settling in period for new technology. This included a lack of shared understanding by everyone as to how to use the systems and gather the right information from them. This information was crucial to effectively monitor and audit how they were improving the service received by people living in the home. This regulation remained in breach.
Additional concerns were also found that led to a further three breaches of the regulations. There was a lack of formal consent being gathered from people in the home and the lack of decision specific capacity assessments and best interest decisions. This was specifically the case for restrictive practice such as bed rails and when medicines were given covertly. This means when they were given to people in their food or mixed into drinks to ensure people took the medicines they needed to stay healthy. People are not supported to have maximum choice and control of their lives and whilst staff do support them in the least restrictive way possible; the policies and systems in the service do not support this practice to be completed in line with the requirements of the regulation.
The second breach noted on this inspection was that there were not enough staff on through the night and the allocation and role of staff during the day required more thought. Senior carers were undertaking roles of kitchen assistant at breakfast time and carers were delivering food to people. This was at a time when people needed most support to get ready for the day.
We also found people were not involved in reviews of their care plan. This meant they were not offered opportunities to tell staff when they required more support, and some people told us they were now needing more support but were not receiving it We saw some care plans identified risks and showed how people should be supported to minimise them. We saw occasions when this did not happen. This included someone being offered biscuits as snacks when they were diabetic and additional support not being offered to another when their blood sugar went higher than acceptable levels. People were not always receiving person centred care because they had not been involved in determining what support they needed.
We have made three recommendations following this inspection, which include; ensuring a suitable audit tool is used to assess the suitability of the environment for the people living in the home. Any action identified should be completed in a timely manner to ensure the building and environment is supporting people living there. We have recommended the provider ensures actions are taken around medicines including the completion of topical medicines administration records, availability of protocols for as required medicines and immediate action to ensure medicines are kept at the correct temperature when stored. Lastly, we have recommended work is completed to assess and meet the preferred preferences of people including their diet, where they would like to spend their time, the decoration and use of the premises and the support and care they receive.
Comprehensive care plans ensured people received the support they identified they required. More staff would enable the care plans to be completely up to date. Information required to assess changing needs prior to additions to the care plan was missing. Once included there would be a better measure if changes in support provided reduced risks and met associated needs.
People told us they liked the staff and they were given choices throughout their day. There was a programme of activities which was well developed and delivered. There would be scope for an additional coordinator to deliver more of the programme in place to a greater number of people in the home.
Staff and people in the home had developed positive relationships and the keyworker system due to be launched would better embed this.
We found staff were sufficiently trained to meet people’s needs and had been safely recruited. Once in post staff sought advice and support as required to deliver care and support safely.
The building was well maintained and professional testing of equipment was undertaken. Appropriate action had been identified on how to support people in the event of an emergency. The home had effective systems in place to manage and control the spread of infection.
Whilst the mealtime experience required more thought and preferences of what and how people ate were still to be acquired. In general, people were supported with good nutrition and hydration. Where risks were identified action was taken.
Professional support was acquired as needed to support people with long term conditions and their general health. This included visiting chiropodists, opticians and diabetic nurses.
You can see what action we told the provider to take at the back of the full version of the report.