Thornton Hall & Lodge

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

People were protected from potential harm and abuse. Appropriate systems were in place to identify, record and report safeguarding concerns. Processes were in place to ensure the safe recruitment of staff and staff had received training in all mandatory areas to equip them to carry out their roles safely. People’s care records showed risks were identified, assessed and measures on how to manage and reduce risks was made clear to staff. Medicines were managed safely and effectively. Staffing levels had sometimes fallen below the required level due to sickness absence. We were assured the manager was taking action to reduce this risk. Effective systems were in place to identify and address any shortfalls in relation to infection control practices.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Our observations found people were supported to stay safe from harm and neglect. Staff were observant of risk in the environment and took the necessary action to reduce the risk of harm.

Appropriate systems were in place to identify, record and report safeguarding concerns. A review of any safeguarding referrals made to the safeguarding authority was undertaken monthly to identify patterns and trends and to establish if lessons could be learnt. We identified good practice with the introduction of a safeguarding group to share good safeguarding practice, discuss safeguarding investigations and any action that needed to be implemented.

Overall, people felt safe living at Thornton Hall & Lodge. Comments included, "I feel happy here" and "I get looked after." Relatives also felt their loved ones were kept safe and confirmed they were well supported and protected by staff.

Staff told us they were familiar with the providers safeguarding policy. They described how they would not hesitate to raise any potential safeguarding concerns. If concerns were raised, staff told us support was provided by the registered manager who worked hard to make things right. They confirmed the culture amongst staff and leaders was open and transparent. The registered manager told us how they treated any safeguarding concerns seriously, making appropriate referrals to any external agencies when required.

People told us they were supported to manage their individual risks and were supported to keep themselves safe. People told us staff checked on their wellbeing through the night. There was a balanced and proportionate approach to risk that supported people and respected the choices they made about their care.

The registered manager understood the importance of monitoring risk and told us this was effectively managed through the electronic care planning system. They told us regular meetings were held to discuss the changing needs of the people they supported to ensure this important information was shared amongst the staff team. Staff we spoke with confirmed this was standard practice.

People’s care records showed risks were identified, assessed and measures on how to manage and reduce risks was made clear to staff. Risk assessments were reviewed on a regular basis to ensure they remained relevant to people's current needs. We found risks relating to continence care and skin care were managed safely.

People had access to the necessary equipment to keep them safe. When people required specialised mattresses to reduce risks associated with their skin, we observed these were in place and when people required monitoring equipment to reduce the risk of falls, we observed these were in place.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us staff were often very busy and described how they sometimes had to wait for assistance. A person told us, "They never have enough staff." People and their relatives also told us staff turnover was high. People and relatives felt staff supported people well.

Staff told us enough staff were rostered however, they were often understaffed due to staff sickness. A staff member told us, “We try to respond to people as quick as we can.” Staff told us they received the training and support they needed to carry out their roles effectively. They spoke positively about the induction they received and told us they were given an opportunity to shadow experienced staff so they better understood the requirements of the role. The registered manager was honest about the recent challenges sickness absence caused and the impact this had on people living at the home. They understood the importance of addressing concerns with staff performance and outlined the action they had taken to reduce the level of absence. They told us the use of temporary agency staff had already reduced following this action.

Staff were observed to be very busy and while they responded to people's immediate needs this was not always timely. For example, we observed delays in staff answering people's call bells and on two occasions we observed people were looking for staff for support but staff were not always visible. We also found that staff were sometimes task focused in their approach to people's care. We shared our findings with the registered manager who committed to undertaking further reviews of staff deployment.

Rotas showed staffing levels had previously fallen below the required levels due to sickness absence. We found no evidence people had been harmed as a result and we were assured the registered manager had taken sufficient action to address this concern through the performance management of staff. Processes were in place to ensure the safe recruitment of staff. Staff had received training in all mandatory areas to equip them to carry out their roles safely.

Effective systems were in place to identify and address any shortfalls in relation to infection control practices. Audits showed timely action was taken to address any concerns about cleanliness. Records we viewed demonstrated the registered manager consulted the local authority infection prevention and control team and the most recent audit completed by the team showed they were satisfied with current processes in place to reduce the risk of infection to the people living at the home. A detailed policy was in place to guide staff which references infection control best practice guidance.

Our observations found most areas of the home were clean and there were no mal odours. We found there was a plentiful supply of soap and hand towels in bathrooms and PPE was available for staff use. We did identify cleanliness concerns in satellite kitchens during lunchtime. However, we shared our findings with the registered manager and the concerns were immediately rectified.

People were involved in identifying and managing risks relating to infection and hygiene. People told us they were happy with the cleanliness of their home.

Staff told us there were adequate supplies of PPE available. They could clearly describe how to change PPE, this practice was consistent with best practice guidance. Domestic staff were knowledgeable about the level of cleaning required to reduce the risk of infection spread.

Staff described the processes they followed to ensure medicines were managed safely and effectively. They told us, at the end of each shift, a medicines count was completed which helped to lessen the risk of errors. Staff were clear about their role and responsibilities in relation to medicines and policies helped to support their practice.

Adequate processes were in place to ensure the safe management of medicines. An electronic medicines administration system (EMAR) was in place which ensured medicines were given in a safe and timely way. For example, for people who required medicines where a specified interval of time was required between doses, such as pain killers, the EMAR system would not permit the medicine to be given prior to the time lapsing. This helped to reduce the risk of medicines errors. Medicines were stored safely and accurate records of medicines administration were maintained.

People received their medicines safely. For people who lacked the mental capacity to make decisions about medicines, we saw the relevant people were involved in making decisions in the persons best interests, this included a GP and a pharmacist.