Thorndene Residential Care Home

On this page

• Overview
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• 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 requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to safe care and treatment.

This service scored 45 (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 did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. The electronic care planning system could generate information to be used when people transferred between services. However, care plans were not always up to date so did not always reflect people’s current needs.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. A safeguarding record was in place but there was no overview of open safeguarding concerns. People told us they felt safe using the service. One person said, “I’m definitely safe, they are all really nice people and make sure you’re alright.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks associated with people's care were not always identified and managed to keep people safe. One person required support to maintain skin integrity, however there was no guidance for staff to follow in the persons care plan and no documentation about how to manage this risk. Another person used a stand aid and a glide about commode. The care plan did not offer any guidelines for staff in the use of this equipment. Another person required a soft and bite sized diet and to ensure meals were appropriately textured and easy to consume. There was no direction given in reference to any dietary preferences or what to offer this person to ensure they received the correct dietary intake.

The provider did not always assess or manage the risk of infection. One person told us the staff always wore gloves and aprons. However, a relative said, “Staff use disposable gloves, and they had been dropped all over the pathway and road outside the property which wasn’t acceptable.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. At our last assessment we found protocols in place to manage medicines prescribed on an ‘as and when’ required basis, were not detailed enough. At this assessment we found no improvements had been made. The provider could not always evidence that people received their medicines as prescribed. Some entries on medication administration records were not clearly completed, with some missed signatures. We also found handwritten entries on the medication administration records, were not double signed, therefore no check that medication had been documented correctly.