Thistle Hill Care Centre

Thistle Hill Care Centre is a nursing home providing personal and nursing care for up to 85 people. At the time of the inspection 81 people received a service. Thistle Hill Care Centre accommodates people across three separate wings with their own adapted facilities. The Deighton wing supports people living with Dementia, the Ripley wing supports people with physical nursing needs and the Farnham wing supports younger adults with physical health needs. The premises are fully accessible with a lift to access the Deighton wing. Ripley and Farnham are on the ground floor.

People's experience of using this service and what we found

Checks to maintain a safe and clean environment were completed and recorded. The provider had an up to date infection prevention and control policy in place for staff to follow. The policy would benefit from a review to ensure it remained effective and considered all latest guidance to keep internal areas of the home free from odours that were offensive or unpleasant.

Staff had good access to personal protective equipment to manage the risks associated with the spread of infection including COVID-19 and adhered to government guidance to protect people.

People received initial assessments of their needs and information, including risks to formulate care plans for staff to use as a point of reference when supporting people. For example, care plans included personal emergency evacuation plans (PEEPs), to ensure required levels of support were quickly provided to support any safe emergency evacuation of the home.

The provider had good governance procedures in place which were used to manage and check service quality. Any areas identified for improvement were logged and actions implemented. Oversight was used to evaluate repeating trends. For example, where people were at risk from falls, outcomes were used to reduce further incidents by ensuring people maintained their mobility in a safe way, with access to any required equipment and support.

People told us they felt safe with the staff who supported them. Staff were clear on types of abuse to look out for and how to raise their concerns when required. The registered manager understood their requirement to notify relevant organisations to ensure any safeguarding allegations were routinely investigated with any outcomes and actions implemented.

Where people required support to take their medicines this was completed safely as prescribed. The provider worked closely with other health professionals and supported people with any required referrals to maintain their health and wellbeing.

Staff were safely recruited into their roles and were supported with a range of training and support to perform their duties. This included observations of their practice and regular supervisions.

People told us they were happy with the service they received. They told us they were confident in approaching staff and the registered manager with any concerns and that any feedback or suggestions would be responded to.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People told us they felt a part of the community where they lived and enjoyed good access to a range of relevant activities.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 26 July 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Thistle Hill Care Centre on our website at www.cqc.org.uk.

Recommendations

We have made a recommendation for the provider to review their policy and procedures for the management of unpleasant odours in the home. We found no evidence during this inspection that people were at risk of harm from these concerns.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The service offered a variety of virtual events and activities for people when they were unable to leave the home.

The home had two purpose built, accessible, visiting pods outside for people to use when it was not possible to come into the home.

Where visits inside the home were not possible, a variety of alternatives were offered.

Thistle Hill Care Centre is a nursing home providing personal and nursing care to 70 people at the time of the inspection. The service can support up to 85 people.

Thistle Hill Care Centre accommodates people across three separate wings with their own adapted facilities. The Deighton wing supports people living with Dementia, the Ripley wing supports people with physical nursing needs and the Farham wing supports younger adults with physical health needs.

The premises are fully accessible with a lift to access the Deighton wing with Ripley and Farnham being on the ground floor.

People’s experience of using this service and what we found

Quality assurance systems were not robustly operated to monitor the quality and safety of the service provided.

Not all incidents were notified to the Care Quality Commission (CQC), which the registered manager is legally required to do.

People were not always kept safe. Staff did not follow infection prevention and control guidance correctly and personal emergency evacuation plans (PEEPs) were out of date or not fully completed. Staff training was not robust, and lessons learnt from mistakes were not shared with the staff to prevent reoccurrence.

The service had safeguarding systems in place and medicines were managed safely.

The registered manager promoted a positive person-centred culture; they involved people and their relatives in decisions about the service. There were good working relations with partner organisations who regularly visited the service.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 17 July 2018).

Why we inspected

We received concerns in relation to the management of medicines, moving and handing techniques, staffing levels and the dignity people received. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Thistle Hill Care Centre on our website at www.cqc.org.uk.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Thistle Hill Care Centre is situated in Knaresborough and provides nursing care for up to 85 younger adults or older people, who may be living with dementia or a physical disability. The home is divided into three units. The Deighton unit provides care for up to 41 people who may be living with dementia. The Ripley unit provides care for up to 24 older people who require general nursing care and the Farnham unit provides care for up to 20 younger adults with disabilities.

Inspection site visits took place on 8 and 10 May 2018 and were unannounced. At the time of this inspection there were 62 people living at the service.

At the last inspection in March 2017 we identified a breach of regulation in relation to good governance. This was because the registered provider had failed to ensure effective systems or processes to assess, monitor and improve the quality and safety of the services provided and mitigate risks, had not been operated.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, effective and well-led to at least good. At this inspection we found the provider had implemented their action plan and were no longer in breach of regulation.

There was a new manager in post who had registered with CQC in November 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Effective quality assurance processes were now in place and were used to identify shortfalls within the service. Timely action had been taken when shortfalls or concerns had been found. The registered manager was supported by a senior management team who visited the service on a regular basis to monitor improvements that were being made.

The use of agency staff was still high but the registered manager ensured only agency staff that were familiar with the service were used. Agency staff profiles were available and contained the required information to evidence they had the skills, knowledge and experience to support people at the service. Safe recruitment processes had been followed and appropriate pre-employment checks were completed.

There was enough staff on duty that had been deployed effectively. Calls bells were answered in a timely manner and staff were visible throughout the service.

Medicines had been managed, administered and stored appropriately. Staff competencies with regards to medicines had been assessed which ensured they had the relevant skills and training to administer medicines safely.

Risk assessments were in place where required and contained sufficient information. Staff were aware of their responsibilities in relation to safeguarding and referrals to the local authority had been made when required.

People were supported to maintain a balanced diet and there was a variety of meals on offer as well as refreshments and snacks throughout the day. Appropriate monitoring tools were completed to highlight any concerns in relation to weight loss or gain. Where concerns were identified, appropriate professionals had been contacted.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

Staff received effective support from the management team. Regular supervisions and observations of practice took place as well as annual appraisals. These gave staff the opportunity to develop within their role. Regular training had been completed in areas the provider considered mandatory as well as specialist training where required.

Staff treated people with dignity and respect. They were familiar with people’s needs, likes and dislikes and how best to support them. Positive relationships had been developed between people and staff.

Care plans contained person-centred information and focused on how people wished to be supported. A range of activities were available and people said activities were much improved. The registered manager had begun to build relationships within the local community.

Resident and relative meetings had been reintroduced and feedback had been sought via satisfaction surveys. People spoke positively about the management team and the improvements they had made to the service.

Thistle Hill is registered to provide nursing care for up to 85 younger adults or older people, who may be living with dementia or a physical disability. The home is divided into three units. The Deighton unit provides care for up to 41 people who may be living with dementia. The Ripley unit provides care for up to 24 older people who require general nursing care and the Farnham unit provides care for up to 20 younger adults with disabilities. At the time of this inspection, there were 61 people living at the service.

There was a registered manager in post who had registered with the Care Quality Commission (CQC) in July 2016. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last comprehensive inspection on 26 July 2016, we identified breaches of regulations. The registered provider had failed to deploy sufficiently qualified and competent staff and effectively monitor and assess the quality of the service being provided. We found that staff did not have the competencies and skills to care for people safely and the needs and preferences of people were not always adequately reflected in care practices and documentation. We asked for and received an action plan telling us what the registered provider was going to do to ensure they were meeting the regulations.

The service was placed into the low levels concerns process with the local authority in September 2016 due to the number of concerns which had been raised by visiting professionals and CQC. At the time of this inspection, Thistle Hill were no longer in the low levels concerns process as the local authority had recognised improvements that had been made.

At this inspection, we found the registered provider and registered manager had begun to implement their action plan and stead progress was being made. We found that the registered provider was still struggling to recruitment permanent staff and the use of agency staff was still high, although this had reduced in recent months. We found some concerns still outstanding including the deployment of staff and a continued breach of one regulation relating to good governance.

You can see what action we told the provider to take at the back of the full version of the report.

Overall, people told us they felt safe. Staff understood how to safeguard people from abuse and were confident the registered manager would deal with any concerns raised appropriately. Referrals had been made to the local authority safeguarding team when required.

People, relatives and staff we spoke with expressed mixed views regarding staffing and the continued use of agency staff. We saw from the rotas that staffing levels were based on the provider’s assessment of people’s needs and occupancy levels but staff were not always deployed effectively.

Risk assessments had been developed and contained relevant information. However, we found that these were not always in place when needed. Accidents and incidents had been thoroughly recorded and appropriate action had been taken to reduce the risk of reoccurrence.

We found gaps in medicine administration records and some of the staff we spoke with were not aware of the correct procedure to follow if they identified any concerns. The administration of topical medicines, such as creams, was not always recorded. Medicines were stored safely and staff competency assessments had been completed.

We have made a recommendation about the management of some medicines.

Safe recruitment procedures had been followed. Recruitment files showed that appropriate checks had been made on the suitability of the employee and staff had received a thorough induction when they joined the service.

Staff had completed a range of training and specialist training had been provided when relevant. We saw that supervisions had begun to take place and staff we spoke with confirmed this. However, the supervisions had not been completed as frequently as the registered provider's policy stated. Annual appraisals had not yet taken place.

Care plans we looked at contained a range of capacity assessments, but the amount of detail was inconsistent. We found that appropriate capacity assessments were not always in place regarding the use of physical interventions. Staff told us they knew what ‘Deprivation of Liberty Safeguards’ (DoLS) meant and the implications for people of having a DoLS in place.

People were supported to maintain a balanced diet. People's weights were monitored and recorded on a monthly basis. We observed lunch time routines on all three units and found that support was provided in a dignified way. People had mixed views regarding the quality of the meals on offer. We could see there was a shortage of staff in the kitchen and other staff, such as the activities coordinator, were being utilised to cover the short fall.

Care records contained evidence of close working relationships with other professionals to maintain and promote people’s health. We could see that referrals to these professionals had been made in a timely manner and these visits were recorded in people’s care records. People confirmed staff were proactive in seeking professional advice.

We saw that staff responded to people’s needs in a timely manner but this was not always consistent on the North Deighton unit due to the deployment of staff. Staff explained to us how they respected a person’s privacy and dignity by keeping curtains and doors closed when assisting people with personal care, and by respecting their choices and decisions.

Care plans were produced to meet individual’s support needs and were reviewed on a regular basis. Care records contained person-centred information but this was not always up to date.

People were aware of how to make a complaint and told us that the registered manager listened to concerns raised. However, we found that complaints had not always been managed appropriately. A copy of the registered provider’s complaints policy was displayed at the service.

People had mixed views about the activities on offer at the service. On the first day of inspection the activities coordinator had been requested to support kitchen staff so there were very little activities taking place. We saw evidence such as photographs which showed activities were on offer.

People and staff spoke positively about the registered manager and recognised the improvements that had been made. Staff felt supported and were confident in approaching the registered manager with any concerns. The registered manager had begun to seek feedback on the service being provided from people, staff and relatives.

We found some of the quality assurance systems were working well, but others needed to be improved to ensure people received a consistent, quality service. Notifications had been sent to the CQC as required by legislation.

Our previous inspection report was published in December 2015. The service was given an overall quality rating of ‘Good,’ with a rating of ‘Requires improvement’ for the key question ‘Is the service well led?’ A recommendation was made regarding the approach of management and how a more open and responsive culture could be developed, where staff and others would feel confident their feedback was listened too.

Thistle Hill is registered to provide nursing care for up to 85 younger adults or older people, who may be living with dementia or a physical disability. The home is divided into three units. One provides care for up to 41 people who may be living with dementia and is called the Deighton unit. One provides care for up to 24 older people who require general nursing care and is called the Ripley unit. The third provides care for up to 20 younger adults with disabilities and is called the Farnham unit.

The service had a registered manager, who registered with us in July 2016. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered provider used a dependency based tool to determine what staffing levels should be. However, we found the deployment of staff was not always effective and that on-going, regular use of agency staff had impacted on the care and support people received. People who used the service and their relatives told us they had experienced times when staff had not been available to meet people’s needs and that this was a recurrent issue they had raised with the registered provider. We also observed this during our visit, when we saw staff struggle to provide the care and support people needed during a lunch time meal. We have required that the provider make improvements.

We received variable feedback from staff about the training and support provided. Some staff did not feel that their training and support and supervision needs were well met and the limited records available to us supported this. People who used the service and relatives were complimentary about the dedication and approach of permanent staff, but told us there were too many agency staff working at the home who were not sufficiently familiar with people’s needs. This meant people did not experience a consistent quality of care. We have required that the provider make improvements.

There was a recruitment procedure in place, which included checks on staff to ensure they were suitable to work with people who may be vulnerable. However, some staff records did not contain full employment histories, or explanations of gaps. In the absence of adequate documentation, we have recommended that the registered provider review their internal selection and recruitment arrangements and take steps to improve the maintenance of staff records.

People did not receive a consistent quality of person centred care. Some people and relatives were satisfied with their care, while others expressed frustration, describing a lack of involvement and consistency. The safety and quality of people’s care varied depending on which staff were on duty and how well they knew people’s needs. We found examples where people had not received safe care and treatment. Some of these matters were still under investigation by CQC together with the police and Local Authority. We have required that the registered provider make improvements.

A complaints procedure was in place and a record of concerns and complaints showed what had been done in response to concerns raised. However, people were not confident that concerns and complaints were listened or responded to effectively by the registered provider. We have recommended that the provider review their own internal arrangements to communicate and respond to people who use the service and their representatives in order to improve communications and confidence.

There was a registered manager in post and a deputy manager had been recruited to provide additional management support. People who used the service, relatives and staff were generally positive about the local management at the home and the efforts they were making to improve the service. However, we found that there was a disconnect between the views of the registered provider’s senior management and what people who used the service, their relatives and staff told us about their experience of living and working at Thistle Hill. Relatives expressed frustration with “head office” and the “hierarchy in Barchester,” and did not feel that they were open or listening to their concerns. Staff said they did not feel valued. We have required that the registered provider make improvements.

Activity coordinators were employed to provide activities and social stimulation. People spoke highly of the input from these staff and there was evidence of some activities taking place and some focused individual interactions taking place. However, we received feedback from people suggesting that a more person centred and individual approach to activities was needed, particularly for people who spent the majority of time in their rooms.

Staff knew how to report any concerns about people’s welfare and safeguarding alerts had been made.

Procedures were in place to guide staff on the safe administration of medicines. Staff could explain how medicines were managed safely and we saw safe storage arrangement in place. The records we checked showed that people had received their medicines as prescribed.

We received positive feedback from three health care professionals who regularly visited the service. They told us they were involved appropriately in people’s care and felt that good arrangements were in place to enable people to access their services. They felt the service was improving and staff were trying hard to ensure people were well care for.

The service had policies and procedures to guide staff on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Deprivation of Liberty Authorisation requests had been made if staff felt that someone lacked capacity to consent to their care and treatment at Thistle Hill.

Audits and checks had been completed by senior management and the manager and deputy manager. Resident and relatives meetings had commenced on a three monthly basis and records of these evidenced frank discussions around the issues and concerns that people had raised. The deputy manager was able to show us the clinical governance arrangements they had put in place and the actions arising from these to make improvements.

We identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we took at the back of the full version of this report.

We spoke with five relatives, six people who used the service and some of the staff on duty. Before people received any care or treatment they were routinely asked for their consent. People we spoke with who lived at the home and their relatives were able to tell us about their involvement in decisions about people's daily lives and specific care needs.

We saw from people's care plans that people were supported to live as independently as possible. Staff at the home had carried out an assessment of the needs of each person, and kept this under review, to enable appropriate care and support to be given.

People who lived at the home were protected from risks of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

Records we looked at also confirmed that staff received good training in areas such as safeguarding adults, infection control and first aid. Staff we spoke with told us that they received good support from their line manager. Records we looked at confirmed this.

The home had systems in place to make sure people were safely cared for. This included policies and procedures and quality monitoring systems.

We found that people had been supported to be involved to make decisions about their care wherever possible. We also saw appropriate arrangements had been put in place where people did not have capacity and needed support to make those decisions.

Medication was being given in accordance with people's prescriptions and needs. We saw people had their medicines when they needed them and they were given in a safe way.

We observed during our inspection that call bells were attended to immediately and when people needed extra support in the dining room staff were available to help.

We also looked at people's care records. We found suitable arrangements for planning and reviewing the care people needed was in place. The records were accurate and up to date, which meant people received the care they needed. We saw the home had systems in place to audit all records regularly and they acted on their findings to improve their record keeping.