We carried out a review of the data available to us about Thorncliffe Residential Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Thorncliffe Residential Care Home, you can give feedback on this service.
Thorncliffe Residential Care Home is a residential care home providing personal care to up to 28 people in a three-storey building. The service provides support to people over 65 years. At the time of our inspection there were 26 people using the service.
People’s experience of using this service and what we found
Peoples felt safe in the service. Staff were recruited safely and there were enough staff to meet the needs of people living in the service. Staff were aware of how to recognise and report concerns. Measures were in place to monitor and manage risk. Medicines were managed safely. Infection prevention and control measures were in place and being followed.
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 felt able to make decisions around their daily routines. People were having their diet and nutritional needs met. The provider worked in partnership with other agencies to maintain people’s health and wellbeing. Staff received regular training and supervision.
Peoples were being treated with dignity and respect. People were supported to have visitors to the service and maintained relationships.
People were supported to have person centred care. Activities were being offered at the service and processes and systems were in place to respond to complaints.
Governance polices, systems and processes were in place and were being used to maintain oversight of the service. The registered manager promoted a learning culture. Staff were positive about the service and felt management were approachable and supportive. People and staff were involved in decisions about the service and their views were being sought and acted upon.
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 under the previous provider was good (published December 2018).
We carried out a focused inspection of this service under the new provider (published Dec 2021). At that inspection, we looked at the safe and well led key questions only. The service was rated good in both key questions.
Why we inspected
The service was registered under the new provider in August 2020. This is the first comprehensive inspection under the provider.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Thorncliffe Residential Care Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Thorncliffe Residential Care Home is a residential care home providing personal care to 28 people aged 65 and over at the time of the inspection. The service can support up to 28 people. Bedrooms were located on both the ground floor and first floor and people had a choice of communal areas to use during the day, including outdoor spaces.
People’s experience of using this service and what we found
People overwhelmingly told us they felt safe living in the home and gave us extremely positive feedback on the service. Staff had been trained in safeguarding and knew their responsibilities. Safe systems and processes were in place for the recruitment of staff. Staff told us they felt there was adequate staffing levels during the day however, we received mixed feedback about staffing levels at night time.
We found the home to be clean and free from unpleasant smells. The service was adhering to Government guidance around COVID-19. Risk assessments were in place to keep people safe whilst maintaining their independence. Medicines were stored and managed safely. Effective systems were in place to ensure lessons were learnt from any incidents and accidents.
People, relatives, staff and external professionals gave us positive feedback about the management of the service. The registered manager had effective systems and processes in place to monitor the standard and quality of the service and to drive improvements.
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 12 December 2018).
Why we inspected
We received concerns in relation to staffing levels, high use of agency, care and treatment of people, training, infection control [including concerns about adherence to Government guidance on COVID-19], unpleasant smells and dirty environment, use of slings and the overall management of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
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 remained the same. This is based on the findings at this inspection.
We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
At the time of the inspection there were strict rules in place throughout England relating to social restrictions and shielding practices. The ones that applied to the area this home was located were commonly known as 'Tier Four Rules'. This meant the Covid-19 alert level was high and there were tighter restrictions in place affecting the whole community.
We found the following examples of good practice:
Staff, management and visitors were using personal protective equipment (PPE) correctly and there were procedures in place around the use of PPE. Some aspects of staff shielding at break times needed to be looked at and we saw that by the end of the inspection, improvements had been made in this area.
We noted good practices around the disposal of PPE.
The provider had processes to minimise the risk to people, staff and visitors from catching and spreading infection. These included weekly testing of staff and at least every 28 days for people living in the home. Hand sanitiser and PPE were available throughout the home. There were signs to remind staff, visitors and people about the use of PPE, the importance of washing hands and regular use of hand sanitisers.
Processes when visitors entered the home were robust. This ensured measures were in place to prevent people bringing infection into the home.
Where appropriate, ‘socially-distanced' visits had been taking place. At the inspection however, and consistent with enhanced restrictions in 'Tier Four', these visits had been restricted and were only allowed in exceptional circumstances.
Visiting rules and process were communicated effectively to people using the service and their relatives. We saw alterations to the premises to facilitate a safe visiting area for people to meet their relatives and friends. This was a suitable way of allowing people to see their loved ones when guidance and legislation permitted.
Infection control policy and people's risk assessments had been considered and revised following the pandemic so that people were protected in the event of becoming unwell or in the event of a Covid-19 outbreak in the home.
The provider insisted people were tested before admission and consistent with local guidance, people had not been admitted to the home for the most part of the pandemic. However, at the time of inspection, this position had been reviewed. In line with changes in restrictions and new guidance relevant to the geographical area, the service had started admitting people to assist with the wider health and social care position. We were satisfied the service, staff, people and visitors were following the rules.
People's mental wellbeing had been promoted by use of social media and mobile devices so people could contact their relatives and friends. The registered manager said as people had come out of isolation and allowed into the 'wider' home, a programme of activities had been introduced and staff were encouraging people to participate.
Staff had knowledge of good practice guidance and had attended Covid-19 specialist training. There were sufficient staff to provide continuity of support and ensure safeguards were in place should there be a staff shortage.
The home was clean and hygienic. The service had started a refurbishment programme in early 2020 that had been cut short due to the pandemic. A designated cleaner was working throughout the inspection.
Staff had received Covid-19 related supervision and all had access to appropriate support to manage their wellbeing should it be required.
Further information is in the detailed findings below.