Thorndene Residential Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 35 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. The Service had 2 managers who were in the process of registering with CQC. They were new to the management role and required support from the provider to ensure management systems and processes were effective.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Policies and procedures were in place to support staff and to ensure they were happy at work. Staff had access to a staff handbook and training policy. The provider had a flexible working arrangement policy. Systems were in place to support staff out of office hours and at a weekend. Members of the management team were on call to support staff if required.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The management team were not organised and did not have information readily available. Audits needed to be more streamlined to ensure the management team had a good overview of the service. Audits in place did not identify the concerns we found during the assessment around medicine management, risks, and management of the service. Systems and processes had not improved since our last assessment.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. We saw people's care plans included referrals to healthcare professionals as and when required. The management team felt the service worked well with external professionals. However, advice from healthcare professionals was not always documented to evidence staff had followed their guidance.