Date of Assessment: 23 July to 5 August 2025. The service is a care homeproviding accommodation and personal care. At the time of our assessment there were 13 people using the service. At this assessment we looked at all the key questions and all the quality statements. At our last assessment we found breaches in relation to person centred care, safe care and treatment and good governance. The provider was served a warning notice to address our concerns in relation to good governance. The provider sent us an action plan outlining the actions they would take to improve the service. We carried out this assessment to check improvements. We found the provider had taken appropriate actions to address the concerns we previously found, and improvements had been made. The provider was no longer in breach of regulations. Governance systems and processes had improved and were more effective in identifying areas for improvement. The provider was working with a consultant who were assisting the management team to make sustainable improvements. The management team had improved systems and processes and could evidence they had taken action to improve the service. Accidents and incidents were analysed and trends and patterns were identified to mitigate future risks. Risks associated with people’s care had been identified and actions taken to reduce hazards. The home was predominantly clean, although some areas of the home required refurbishment to ensure they could be cleaned effectively and an action plan was in place to address this. People were appropriately referred to healthcare professionals, and staff took action to follow their guidance. People were safeguarded from the risks of abuse. People’s needs were assessed and reviewed frequently to ensure care delivered was in line with people’s current needs. Staff were kind and caring and supported people in a dignified way. During our assessment we found staff responded to people in a timely way. We found people did not always have access to social stimulation. The management team had started to look at ideas to improve activities both in and out of the home.
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Date of Assessment: 23 July to 5 August 2025. The service is a care homeproviding accommodation and personal care. At the time of our assessment there were 13 people using the service. At this assessment we looked at all the key questions and all the quality statements. At our last assessment we found breaches in relation to person centred care, safe care and treatment and good governance. The provider was served a warning notice to address our concerns in relation to good governance. The provider sent us an action plan outlining the actions they would take to improve the service. We carried out this assessment to check improvements. We found the provider had taken appropriate actions to address the concerns we previously found, and improvements had been made. The provider was no longer in breach of regulations. Governance systems and processes had improved and were more effective in identifying areas for improvement. The provider was working with a consultant who were assisting the management team to make sustainable improvements. The management team had improved systems and processes and could evidence they had taken action to improve the service. Accidents and incidents were analysed and trends and patterns were identified to mitigate future risks. Risks associated with people’s care had been identified and actions taken to reduce hazards. The home was predominantly clean, although some areas of the home required refurbishment to ensure they could be cleaned effectively and an action plan was in place to address this. People were appropriately referred to healthcare professionals, and staff took action to follow their guidance. People were safeguarded from the risks of abuse. People’s needs were assessed and reviewed frequently to ensure care delivered was in line with people’s current needs. Staff were kind and caring and supported people in a dignified way. During our assessment we found staff responded to people in a timely way. We found people did not always have access to social stimulation. The management team had started to look at ideas to improve activities both in and out of the home.
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Date of Assessment: 14 January 2025 to 29 January 2025. The service is a residential care home providing support for up to 22 people. At the time of our assessment there were 16 people living at the service. Some people were living with dementia. At this assessment we looked at the key questions of Safe, Responsive and Well led. We carried out the assessment to follow up some concerns we had received and to check if the provider had continued to embed systems and practices to improve the service. At this inspection we found improvements had not been sustained and further improvement was required. We found breaches of regulation relating to safe care and treatment, person centred care and governance. This means the service needs to make improvements in these areas. We will request an action plan from the provider to understand what they will do to improve standards of quality and safety. We will continue to monitor information we receive about the service.
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Date of Assessment: 14 January 2025 to 29 January 2025. The service is a residential care home providing support for up to 22 people. At the time of our assessment there were 16 people living at the service. Some people were living with dementia. At this assessment we looked at the key questions of Safe, Responsive and Well led. We carried out the assessment to follow up some concerns we had received and to check if the provider had continued to embed systems and practices to improve the service. At this inspection we found improvements had not been sustained and further improvement was required. We found breaches of regulation relating to safe care and treatment, person centred care and governance. This means the service needs to make improvements in these areas. We will request an action plan from the provider to understand what they will do to improve standards of quality and safety. We will continue to monitor information we receive about the service.
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Thorndene Residential Care Home improved from Inadequate to Requires Improvement overall, exiting Special Measures after addressing previous breaches of Regulations 12, 13, 17 and 18. Further embedding of medicines management, incident learning, safeguarding analysis and governance systems is still required to achieve and sustain consistent safe and well-led care.
Concerns (6)
moderateMedication management: “Where people were prescribed PRN medicines, guidance was in place but there was no information recorded about the effectiveness of the medicine following administration.”
moderateIncident learning: “Behaviour charts were used as a record of an incident but they were not written in a way which identified what happened before, during and after the behaviour so learning could be identified.”
moderateGovernance: “Medicines audits were undertaken but improvement was needed to ensure PRN protocols and risk assessments were reviewed.”
minorMedication management: “There were no risk assessments in place for prescribed creams stored in people's bedrooms.”
minorInfection control: “There were shortfalls around cleaning of the laundry area and freezers. The outside bins were overflowing as a result of their position and organisation of the bin area.”
minorSafeguarding: “Safeguarding records were maintained and organised. The information in the records would benefit from analysis to identify causative factors or precursors which would identify learning.”
Strengths
· Risks to people were assessed, monitored and managed appropriately with systems in place to protect people from harm and abuse.
· Sufficient staff on duty to meet people's needs, providing support in a kind and caring manner.
· Provider no longer in breach of Regulations 12, 13, 17 and 18 following significant improvements since previous inspection.
· Positive and calm atmosphere in the home with kind and caring staff reported by people and family members.
· Provider appointed a head of service to oversee improvements and worked closely with infection prevention, commissioners and local fire and rescue service.
Quality-Statement breakdown (9)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Preventing and controlling infectionRequires improvement
well-led: Managers and staff being clear about roles, quality performance, risks and regulatory requirements; Continuous learning; Working in partnershipRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
Engaging and involving people, the public and staff
Thorndene Residential Care Home received an overall Inadequate rating at this focused re-inspection (April 2023), remaining in Special Measures with continued breaches of Regulations 12, 13, 17, and 18 across safety and governance. Persistent failures in safeguarding reporting, risk assessment, medicines management, infection control, and ineffective leadership audits left people at risk of avoidable harm despite some incremental improvements since the previous inspection.
Concerns (13)
criticalSafeguarding: “A recent incident relating to a fall had not been reported to CQC or the local authority, as required. Another incident relating to missed care calls, had not been reported to CQC.”
criticalGovernance: “Audits were not always effective in identifying concerns. For example, daily walk around checks and audits had not identified concerns found in relation to infection control, fire safety, environmental risks, and medicines.”
criticalCare planning: “1 person's records did not contain detail about how to safely support them during incidents of emotional distress, how to provide pressure care or how bed rails should be used safely.”
criticalMedication management: “Staff trained to administer medicines were not available through night-time hours. Meaning, people who may need 'as required' medicines could not be provided with them if required.”
criticalLeadership: “There was a lack of leadership in the service and the providers governance systems were not effective in improving the quality and safety of the service.”
moderateMissed or late visits: “People receiving support from the domiciliary care service were not always provided with staff for their allocated call times, in line with their assessed needs.”
moderateStaff training: “Catheter care and nutritional training was not undertaken.”
moderateIncident learning: “It was not evidenced that all incidents were reviewed by the provider, meaning lessons were not learned from these.”
moderateInfection control: “The kitchen remained visibly dirty. Food items did not contain dates of defrosting, meaning several food items appeared to be out of date. Kitchen audits had not identified concerns.”
moderateComplaints handling: “Records were not in place to evidence any action had been taken to investigate or address this complaint.”
moderateRecord keeping: “The provider and registered manager failed to appropriately audit records. For example, gaps found in kitchen and cleaning records were not identified.”
minorSupervision / appraisal: “Whilst some staff supervisions were in place, improvement was required to bring these up to date.”
minorConsent / capacity: “Consent for CCTV in communal areas of the home, had not been sought.”
Strengths
· A dependency tool had been introduced and people had their needs assessed to determine how many staff were needed to safely support people in the care home.
· People told us they liked the staff and relaxed, positive interactions between staff and people were observed.
· Staff were recruited safely with appropriate pre-employment checks in place.
· Deep cleans had been undertaken, new domestic staff employed, and no malodour was found; the provider continued to work with the IPC team.
· Appropriate referrals to healthcare professionals such as district nurses and dieticians were made.
Quality-Statement breakdown (9)
safe: Assessing risk, safety monitoring and management; learning lessons when things go wrongInadequate
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Using medicines safelyInadequate
safe: Preventing and controlling infectionInadequate
well-led: Managers and staff being clear about their roles; continuous learning and improving care; working in partnership with othersInadequate
well-led: How the provider understands and acts on the duty of candourInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering
Thorndene Residential Care Home was rated Inadequate overall following a focused inspection of Safe and Well-led, representing a deterioration from the previous Requires Improvement rating. Widespread and critical breaches were found across safeguarding, medicines management, infection control, staffing, governance, and record keeping, resulting in warning notices and the service being placed in special measures.
Concerns (12)
criticalSafeguarding: “We found 3 incidents which were not reported to the CQC or the local authority as required. This meant people were not always protected from the risk of abuse.”
criticalMedication management: “Medicines were not stored at the correct temperature and some medicines belonging to people were found to be stored in different areas of the service.”
criticalInfection control: “Some areas of the home were visibly dirty and effective cleaning schedules were not implemented. We found faeces on a light pull switch.”
criticalGovernance: “Effective governance systems were not in place to ensure the quality and safety of the service. There was a lack of overarching governance from the provider.”
criticalCare planning: “Care plans did not contain enough detail to guide staff on how to provide individualised care. Some contained conflicting information about another person.”
criticalStaffing levels: “We could not be assured enough staff were provided to keep people safe. Where people received care at home, one relative told us, 'Staff are routinely late, there is an issue with staffing.'”
moderateStaff training: “Some staff had not received training in pressure area care. Staff had not completed catheter care or nutritional training, which was required to safely support people.”
moderateRecord keeping: “Peoples records were not confidentially stored. We found various records containing sensitive information stored in a communal area.”
moderateConsent / capacity: “The service had CCTV systems in place in the communal areas of the home and people had not consented to this.”
moderateIncident learning: “Accidents and incidents had still not been appropriately reviewed. The registered manager reviewed incidents of falls, however had not reviewed other incidents.”
moderateLeadership: “The registered manager had recently provided care calls to people in the community due to staffing issues, which meant resources were not in place for management and oversight.”
moderatePerson-centred care: “People were not always provided with call alarms to enable them to request support when needed. Care plans did not contain enough detail to guide staff.”
Strengths
· People told us staff were kind and caring; one person said 'The staff are nice, they are fun.'
· Staff were trained and knowledgeable about how to spot signs of abuse and felt able to raise concerns.
· DBS checks were completed for all staff prior to commencing employment.
· Quality assurance questionnaires showed people and relatives were positive about staff kindness.
· Feedback from relatives showed 100% felt staff were friendly and approachable.
Quality-Statement breakdown (10)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Preventing and controlling infectionInadequate
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Using medicines safely and learning lessons when things go wrongInadequate
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInadequate
well-led: Continuous learning and improving care; working in partnership with othersInadequate
well-led: How the provider understands and acts on the duty of candour
Thorndene Residential Care Home was rated Requires Improvement overall for the second consecutive inspection, with three breaches identified in safe care and treatment, staffing, and good governance. Risks were not consistently assessed, medication audits failed to identify CD discrepancies, staffing levels were insufficient (including for the domiciliary service where visits were often late), and governance systems did not detect the issues found on inspection.
Concerns (10)
criticalCare planning: “Risks to people's safety had not always been assessed and recorded. For example, one person who smoked created a potential risk to themselves and others. However, there was no risk assessment in place for this.”
criticalMedication management: “Two records of CD drugs did not tally with the drugs stored... Medication audits were not robust or effective as discrepancies had not been identified.”
criticalStaffing levels: “We were not assured there were enough staff deployed to keep people safe. The provider did not use a dependency tool to ensure there was a safe number of staff”
criticalGovernance: “Governance systems were in place but not always effective. The registered manager's quality audits for medication, risks, infection prevention and control were not effective”
moderateMissed or late visits: “People using the DCA service said often staff did not arrive at the agreed time.”
moderateIncident learning: “Analysis of accidents and incidents did not include all accidents that had happened so could not fully identify any patterns or trends to help mitigate risk and prevent reoccurrence.”
moderateRecord keeping: “We found records of pressure care for people were not up to date. On the day of the inspection staff had not completed the two hourly turn charts for people since the day before.”
moderateInfection control: “the cook was dressed in their outdoor clothing and did not always change the plastic apron when they returned to the kitchen from taking a break outside.”
moderatePerson-centred care: “We saw people living in the care home were left unsupervised whilst eating and for considerable periods throughout the day.”
minorComplaints handling: “Initially when I raise concerns it goes back to being good, but then goes back to the same.”
Strengths
· Staff understood the importance of keeping people safe and registered manager was aware of safeguarding reporting responsibilities
· Referrals had been made to appropriate agencies such as the local safeguarding authority and CQC where incidents occurred
· Provider was meeting shielding/social distancing rules, admitting people safely, and accessing testing
· Management team worked in partnership with community professionals and organisations
· Provider understood the duty of candour and kept people and relatives informed about key changes
Quality-Statement breakdown (10)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated