Thornhill Nursing Home

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

At our last assessment we rated this key question Good. At this assessment the rating had changed to Inadequate. This meant people were not safe and were at risk of avoidable harm. We identified breaches of regulation in relation to safeguarding, safe care and treatment and staffing. We found there were not enough suitably trained staff to meet people’s needs and keep them safe. Risks to people were not managed safely and people were not protected from abuse and avoidable harm. People’s medicines were not managed safely. Some areas of the premises were not clean or properly maintained. Infection control risks were not fully assessed or managed. Staff were recruited safely.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives gave mixed feedback about the learning culture at the service. Some people said they felt comfortable raising any issues with the staff. However, relatives reported concerns they raised had not been resolved, including family members being dressed in other people’s clothes and a broken window pane in a bedroom.

Staff said if they had any concerns they would raise them with the manager and felt confident these would be listened to. However, staff and the manager said they had raised concerns repeatedly about unsafe staffing levels and felt this had not been addressed by the provider.

Processes for supporting a learning culture were not effective in ensuring lessons learnt were consistently identified and accurately recorded. Accidents and incidents were audited monthly. However, not all accidents and incidents were captured in the audit. Lessons learned were limited to actions taken in response to individual events and did not include any wider learning. For example, the audit in February 2024 noted falls during the day had increased and in March 2024 it was noted accidents and incidents had remained high. There was no information to show any actions taken in response to these findings. No trends had been recorded since the audit in May 2024.

People and their relatives said staff supported them in accessing healthcare services. Comments included, “They would get a doctor if I needed one.”

The manager said they supported people to access health and social care services and made sure relevant information about the person was provided. They said pre-admission assessments were carried out before new people were admitted to the home to ensure they could meet the individual’s needs. However, we found there were gaps in the information recorded in people’s care records which impacted on continuity of care and safe transitions.

We did not receive any information from partners in relation to safe systems, pathways and transitions.

Effective processes were not in place to ensure safe systems, pathways and transitions for people. One person had been to hospital due to continuous issues with a medical aid. The person’s care plan did not reflect the outcome of the hospital visit or evidence any request for support from a specialist nurse.

The provider’s admission policy stated prospective new people must have a pre-admission assessment carried out by the home manager or deputy manager. This had not happened with a person who had been admitted from hospital where they had been for a month following admission from a care home. All care plans and risk assessments related to the previous care home and had not been updated 7 days after admission to the service.

We found people were not always protected from abuse or avoidable harm. Most people said they felt safe at the service. Comments included; “I feel safe and I’m not worried about anything” and “I am safe because I can’t go anywhere and I have to rely on them (staff) because I can’t walk.”

Most relatives felt their family members were safe. One relative expressed concerns about staffing levels and the person’s call bell being out of reach. They said, “I don’t think (family member) is safe here as there is never anyone around.”

The manager and deputy manager understood the safeguarding procedures. However, we found appropriate action had not always been taken to protect people when abuse was suspected or found. Safeguarding referrals had not always been made to the local authority safeguarding team or notified to CQC. Staff had completed safeguarding training but were unclear on the processes for reporting and recording accidents, incidents and safeguarding.

We observed people were not always safe and made safeguarding referrals following each of our site visits. We identified areas of neglect in relation to people's skin integrity, risk management, insufficient staffing levels and person-centred care.

We observed a person getting distressed and asking to go outside for some fresh air. Staff said they could not find a coat for the person so they were not taken out. This person had a condition on their DoLS for staff to support them to go out.

Systems and processes were not effective in protecting people from the risk of abuse and avoidable harm. Safeguarding records were inaccurate and audits did not fully capture all safeguarding incidents. The safeguarding log for 2024 showed there had been 4 incidents and these had been referred to the local authority safeguarding team. However, other records identified a further 12 incidents all of which indicated abuse may have/or had occurred. It was not always clear what actions had been taken to support people and to reduce the risk of repeat incidents. The manager did not know if any investigations had been carried out into these incidents. None of these incidents had been referred to the local authority safeguarding team or notified to CQC.

People were not involved or consulted in the risk assessment process. People raised concerns with us about risks. A person told us they had been unable to summon help as their call bell was cancelled when the sensor mat in the room had been triggered. This had not been identified by the manager or staff.

Records showed people were not involved in the formulation or reviews of their risk assessments and care records.

Staff said they did not routinely look at care files which meant they might not be familiar with risk assessments. The manager and deputy manager acknowledged shortfalls in the risk management process. The deputy manager said detailed risk assessments were not done routinely but a separate care plan was developed to manage the risk.

We observed risks to people were not always managed safely and we made safeguarding referrals following each of our site visits.

We observed pressure relieving equipment was not used effectively as specialist mattresses were not set correctly according to people’s weight, putting them at risk of pressure damage. At our next site visit pressure relieving mattresses were still not set correctly despite labels being attached showing the person’s current weight.

We observed people were not being repositioned in accordance with their care plans and repositioning records were not accurate. One person’s care plan showed they had a pressure ulcer and needed repositioning every 2-3 hours. We saw the person in bed on 3 separate occasions in the morning and again after lunch. The person was in the same position each time we checked, yet care records stated they had been repositioned onto different sides. At our next site visit we raised concerns about this person again when we found specialist advice was not being followed in relation to dressing their pressure ulcer and repositioning.

On all 4 site visit days we saw there were risks to people's safety because of insufficient staffing levels. For example, a person on the dementia care unit was verbally very aggressive to other people. This was often unknown to staff because they were not present in the area.

Risks to people's health and welfare were not always assessed and managed safely or consistently placing them at risk of harm or injury. Risk assessments were in place but were not always accurate or up to date. Risk assessments comprised of tick boxes and did not give details of the risk or the actions needed to minimise the risk.

People did not raise any concerns regarding the safety of the environment. However, a relative raised concerns about a cracked windowpane in their family member’s bedroom and the bedroom door closing quickly which they were worried may knock the person over.

However, significant improvements were required in relation to the environment and the checks in place to ensure people’s safety and wellbeing. For example, on one site visit it had been snowing and was very cold outside. People told us they were cold and others felt cold. The heating system was not working effectively. Windows had been left open and people had not been provided with sufficient bedding to keep them warm. This had not been identified by management or staff.

The manager and staff told us there were no maintenance checks in place prior to September 2024 as the service had been without a maintenance person.

On one site visit we raised concerns with the manager and senior staff about the cold temperature in people’s rooms. The manager and staff had not identified any issues although it was evident on walking round the home and going into people’s rooms that they were cold.

We saw the premises were not maintained in a safe condition placing people at risk of harm or injury. For example, some fittings were broken including door handles and a hoist footplate posing a hazard to people. Rooms which contained items that could cause harm to people, such as tools and cleaning solutions, were not secure. The bath on the top floor had been out of use for several months, which meant people had to go down to the first or ground floor if they wanted a bath. There were no room thermometers to monitor the temperature in people’s rooms. The laundry room was not fit for purpose. The room was small and extremely hot in temperature, there was insufficient ventilation and a poor working environment.

Processes in place to monitor and maintain the safety of the premises and equipment in the service were not effective. Issues we identified during our site visits had not been identified or addressed by the provider.

The maintenance file listed the checks to be carried out on a daily, weekly and monthly basis. These were recorded from mid-September 2024 onwards. None of the issues we identified during the inspection were identified in these checks. There were no records of maintenance checks available prior to this date.

Records showed 9 staff were overdue fire drill training and 8 staff were overdue fire evacuation training. This included a senior staff member who would be in charge of a shift and responsible for instigating fire safety measures. This placed people at risk of harm.

People gave mixed feedback about the staffing levels. Some people felt there were enough staff whereas others raised concerns. Comments included; “No, there is not enough staff it is hard work for them”, “They bring the food then I don’t see anyone for four hours” and “At times they could do with more staff.”

A relative said, “I don’t think [family member] is safe here as there is never anyone around.”

Our observations evidenced there were not enough staff to meet people’s needs.

Staff raised concerns about the staffing levels. Comments included; “Staffing is always an issue. It’s difficult to meet everyone’s needs, you are rush, rush, rush the whole time. We would like to be able to spend more quality time with our residents but we can’t do that because there’s always someone else who needs something” and “Sometimes people have to wait to get up or for their personal cares and that’s not okay. We definitely don’t have enough time to sit and talk with residents and we would like to be able to do that.”

Staff at night described working alone on the different floors and how they struggled to support people and keep them safe.

Staff said they received online training and some face-to-face such as moving and handling. Comments included, “We have modules in autism, diabetes, Parkinsons, dementia, all kinds of specific conditions. We have them as the electronic modules but in terms of real, practical life skills no, we didn’t receive practical training. The modules explain the theory but you have to work out for yourself what that means for a resident and how you might need to help them.”

Staff said they received supervision and some had had their practice observed. Nursing staff said they did not receive clinical supervision.

Our observations on all site visits found there were not enough staff to support people and keep them safe. We observed multiple occasions during the day and night shift when one care staff member was left alone on a floor, placing people at risk of harm. This happened even when there were 2 staff allocated to a floor. For example, when either staff member left to take a break or when the senior staff member was busy with other duties such as giving out medicines. We saw people in communal areas were left unattended while staff supported people in their bedrooms. On several occasions inspectors had to intervene and locate staff to assist people as no staff were available.

On the night shift we saw a staff member working alone trying to clean up a person’s room, monitor people in the lounge, respond to call bells and to people in their rooms calling for assistance.

Staffing was not safe and effective in meeting people's needs and keeping them safe. Systems were in place to calculate safe staffing levels based on people's dependency needs. However, our observations and discussions with staff evidenced staffing levels were insufficient and the deployment of staff was not effective.

The training matrix showed not all staff were up to date with their training. Only 9 out of 42 staff were 100% up to date with training the provider had deemed mandatory.

The manager was unable to provide evidence to show that nursing staff were trained and assessed as clinically competent in relation to catheterization, wound care and syringe drivers.

Staff were recruited safely. Records showed some staff had received supervision sessions.

People and relatives did not raise any concerns about the standards of cleanliness. One relative said, “Her room is clean apart from the old fabric of the building.”

We found parts of the home were not clean and safe infection control practices were not implemented.

Staff told us the working conditions in the laundry were difficult and said they had raised concerns on several occasions. They said when they arrived in the morning they sometimes had to step over all of the dirty washing to get into the room as it was overflowing out of the doorway. They said they disposed of contaminated items such as personal protective equipment (PPE) and red bags in a general waste bin at the end of their shift. These actions did not comply with safe infection control procedures.

We saw standards of cleanliness were not maintained as some parts of the environment were not clean. For example, furnishings and fittings were dirty, some surfaces were damaged and unable to be cleaned properly, some bedroom carpets were heavily stained and there was a strong odour of urine.

The laundry room was not clean or in a good state of repair. There were not effective systems in place to separate clean and dirty laundry. Hand washing facilities were insufficient with dispensed soap but no evidence of paper towels. Suitable facilities were not in place for laundry staff to dispose of personal protective equipment and other contaminated waste safely. Laundry staff were not complying with safe infection control procedures.

We saw the infection control procedures the manager told us they had implemented, for a person who had an infectious condition, were not in place.

Processes in place to assess and manage infection control risks were not effective.

Infection control procedures were not implemented for a person with an infectious condition placing other service users and staff at risk of cross infection. There was no reference to the condition or infection control arrangements in the person’s care records.

We received mixed feedback from people about their medicines. Comments included; “I have some medication, sometimes [staff] stay with me [while I take it], sometimes they don’t” and “I get my medication regularly.” One person showed us their sore and itching skin which they said was ‘driving [them] insane’. We found staff were applying a cream to the skin which had been discontinued. Another person was prescribed eye drops and said they did not always get their eye drops when they should. Inspectors saw the person’s eye was red and weeping. Medicine administration records showed the eyedrops had not been administered on 2 occasions.

Staff did not always seek prompt medical advice when required. A health care professional, who was visiting a person, raised concerns with the inspector about the person’s skin condition. The inspector raised this with the senior care staff member who was unaware of the skin deterioration. Following our intervention staff contacted the GP.

Our discussions with staff showed people who were prescribed medicines to be given at a specific time were not receiving these in accordance with the prescriber’s instructions. This meant the medicines may not be safe or work effectively.

Safe systems were not in place to ensure medicines prescribed ‘when required’ (PRN) could be administered safely. PRN protocols did not have enough person-centred information recorded to ensure the medicines could be given safely and consistently. Medication administration records (MARs) showed people’s medicines were not always administered as prescribed. One person was prescribed a thickening powder to thicken their drinks due to swallowing difficulties. The thickening powder had run out meaning the person could not safely be given a drink as this would put them at risk of choking. A senior manager requested an urgent prescription when this was raised by the inspector. We found some medicines were not kept safely. This had been addressed when we visited on the second day. Audits were effective in identifying shortfalls in medicines management. However, issues of concern found in September and October 2024 had not been acted upon.

Government patient safety alerts were checked and actioned when relevant. Stocks of controlled drugs were checked regularly.