Thorndene Residential Care Home

Updated 17 January 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 2 inspectors and a regulatory co-ordinator.

Service and service type

Thorndene Residential Care Home is a 'care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Thorndene Residential Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Thorndene Residential Care Home also provides a domiciliary care agency. It provides personal care to people living in their own houses and flats.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post but they were off work. The head of service was on site and facilitated access to the service, records and paperwork.

Notice of inspection

This inspection was unannounced. Inspection activity started on 4 December 2023 and ended on 20 December 2023. We visited the location’s service on 4 December 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service including the local Healthwatch organisation. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 4 people and 2 family members to gain their feedback of the service. We spoke with 4 members of staff, including the head of service, team leaders and a support worker. We observed people in the dining room, the lounges and in their rooms. We reviewed 4 care records, a variety of medicines records and various records relating the management of the service.

Updated 17 January 2024

About the service

Thorndene is a residential care home providing accommodation and personal care to up to 22 older people, some of whom live with dementia. Accommodation is provided across 2 floors with a communal lounge and dining area on the ground floor. At the time of our inspection 11 people used the service.

From this location a domiciliary care service was also provided. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of this inspection 27 people received assistance with their personal care needs.

People’s experience of using this service and what we found

The service had improved since the last inspection; however, further improvements were still required. People and relatives were happy with the service and told us they felt safe.

Management of medicines had improved since the last inspection, but improvements needed to be embedded and reviewed. We recommended medicine audits include a review of how the effectiveness PRN (as required) medicine is recorded and checks on risk assessments for creams kept in people’s rooms. The provider took action to address these recommendations immediately following feedback at the time of inspection.

Risks to people were assessed, monitored and managed appropriately and systems were in place to protect people from harm and abuse. The provider had acted to manage infection risks and there were enough staff on duty to meet people’s needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The provider had made improvements to the way in which the service was led and managed. These improvements needed to be embedded and sustained. We made a recommendation about the continued use of an action plan approach to implement changes and developments to embed and sustain the improvements the service had made.

There was a calm and happy atmosphere in the home. Staff were kind and caring and it was clear improvements had been made since our last inspection.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 6 July 2023) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

This service has been in Special Measures since 10 February 2023. During this inspection the provider demonstrated improvements had been made.

The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this inspection to check whether the Warning Notices we served previously, in relation to Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, had been met. This focused inspection checked the provider had followed their action plan and to confirm they now met legal requirements.

This report only covers our findings in relation to the Key Questions Safe and Well-Led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We have found evidence that the provider needs to continue to make improvements. Please see the safe and well led sections of this full report.

Recommendations

We have made recommendations about reviewing how the effectiveness of PRN (as required) medicine is recorded and risk assessments for creams kept in people’s rooms. We also made a recommendation that the service should continue to use an action plan approach to sustain and embed the improvements made since the last inspection.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.