We inspected Thornbury Residential Home on the 23 October 2017. This was an unannounced inspection. Thornbury Residential Home provides accommodation, care and support for up to 19 people. On the day of our inspection 16 older people were living at the home aged between 75 and 99 years. The service provides care and support to people living with diabetes, sensory impairment, risk of falls and long term healthcare needs.

A registered manager was in post. 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 and associated Regulations about how the service is run.

We inspected Thornbury Residential Home in July 2015 where breaches of Regulation were found. As a result we undertook an inspection in July 2016 to follow up on whether the required actions had been taken. Although we found improvements had been made, there remained areas that required improvement and it was rated as requires improvement overall. We asked the provider to make improvements to ensure people’s safety and welfare had been protected by adequately assessing risk, that peoples care records were complete and accurate and that quality assurance systems improved. The provider sent us an action plan stating they would have addressed all of these concerns by July 2017. This unannounced comprehensive inspection on the 23 October 2017 found that whilst there were areas still to improve and embed in to everyday practice, such as auditing processes, there had been significant progress made and that they had now met the breaches of regulation.

People spoke positively about living at Thornbury Residential Home. Comments included, “It’s my home” and, I’m very happy here.”

Robust systems had been introduced since the last inspection to assess quality and safety. These included audits for infection control, the environment and equipment used, medicines and daily notes. The registered manager used a variety of methods to assess and monitor the quality of the service. These included regular audits, staff and 'resident' meetings to seek their views about the service provided and their opinions to improve the home.

This inspection found care plan systems had been improved to ensure they reflected peoples changed needs and mitigated potential risks to their health and safety. People who relied on pressure relieving mattresses to reduce the risk of pressure damage had mattress settings checked daily to ensure maximum benefit. Records reflected the care that was being provided by care staff and it was individual to their identified needs. The registered manager had put systems in place to ensure staff followed good practice guidance in respect of kitchen hygiene processes. Accidents and incident reporting had been completed and there was management overview of audit of falls and incidents to prevent a reoccurrence. This meant measures to ensure learning and preventative measures had been taken.

Medicines were managed safely in accordance with current regulations and guidance. There were systems in place to ensure medicines had been stored, administered, audited and reviewed appropriately. Staff had training on keeping people safe and understood the process of reporting concerns. People were protected, as far as possible, by a safe recruitment system. Staff had been checked to ensure they were suitable before starting work in the service. There was sufficient staff at this time to meet peoples’ needs. People felt comfortable with staff and said, “Great staff, caring with a sense of humour.” There was a lot of laughter and banter between people and the staff. We also saw some positive interaction between staff and the people they supported.

The management style was to involve people, relatives and staff in developing the service and, it was clear people

We carried out an unannounced comprehensive inspection at Thornbury Residential Home on the 8 and 10 July 2015 where breaches of Regulation were found. We issued warning notices for two of these breaches. A warning notice includes a timescale by when improvements must be achieved. If a registered person has not made the necessary improvements within the timescale, we will consider further enforcement action.

As a result we undertook an inspection on 7 and 8 July 2016 to follow up on whether the required actions had been taken. Although we found improvements had been made there remained areas that required improvement.

Thornbury Residential Home provides accommodation, care and support for up to 19 people. On the day of our inspection 17 older people were living at the home aged between 77 and 97 years. The service provides care and support to people living with diabetes, sensory impairment, risk of falls and long term healthcare needs.

A registered manager was in post. 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 and associated Regulations about how the service is run.

Although people told us they felt safe living at the service we found the provider had not taken adequate steps to manage risks effectively in areas such as accidents, a person’s nutritional care needs and specialist equipment. We also found kitchen staff had not consistently followed basic food hygiene principles in relation to the storage of food.

People told us there were sufficient numbers of care staff to support them however we found concerns with the deployment of staff at meal times. This resulted in people being left for extended periods of time.

Although staff spoke positively about senior staff we found examples where some staff had not been effectively supported by the provider; issues of concern had been raised which had not been adequately responded to.

The provider had not taken steps to ensure all care plans provided clear person centred guidance for staff on how to respond and manage people’s behaviours that challenged.

Although some quality assurances systems were proving effective at driving improvement the provider had failed to fully implement recommendations following an external quality assurance audit. These unresolved issues remained outstanding during our inspection.

Robust recruitment checks were completed taken place prior to staff working at the home.

Staff communicated clearly with people in a caring and supportive manner. Staff were seen to be caring and treated people with respect and dignity.

Medicines were managed safely in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the manager understood when an application should be made and how to submit one. Where people lacked the mental capacity to make specific decisions the home was guided by the principles of the Mental Capacity Act 2005 (MCA).

People were provided with a range of opportunities to take part in activities ‘in-house’ and to access the local and wider community.

People were supported to maintain good health and had access to on-going healthcare support. People were able to see their GP whenever they needed to. Satisfaction surveys undertaken with health care professionals demonstrated the service liaised effectively with them.

People, staff and visitors were positive about the service and the registered manager. People knew how to raise complaints and concerns and told us they would feel happy to do so if required.

We found breaches in Regulations. You can see what action we tol

The inspection team was made up of two inspectors and a specialist nurse advisor. The focus of the inspection was to follow up on two warning notices issued following our last inspection in August 2014. We answered the questions is the service safe and is it effective?

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

Staffing levels were sufficient to meet the needs of the people living at the home. Rotas showed that the home had taken account of the skills of staff to ensure that junior staff were always supported by more experienced staff. People told us that there were enough staff to meet their needs. One person told us, “I do quite a bit for myself, but if I call staff there is a quick response.”

Records were not always sufficiently detailed to determine how staff dealt with situations. For example, daily records told us what tasks staff carried out for people, but not how their social and emotional needs were met.

Is the service effective?

We saw that people’s needs were regularly reviewed. Records confirmed that people’s preferences, interests and diverse needs had been recorded. When people’s needs changed professional advice and guidance was sought and included in the person’s care plan.

At our last inspection we found that some people were at risk of pressure damage, dehydration and malnutrition. At this inspection systems were in place to ensure that pressure care was monitored closely and that food and fluid charts were updated and analysed regularly.

A relative told us the home was meeting their relative’s needs and praised the manager and staff for the, “Caring, friendly and considerate care” they provided.

Our inspection team was made up of two inspectors and a specialist nurse advisor. This was a follow-up inspection to look at the areas where we had previously asked the service to improve. We answered our five questions; Is the service caring? Is the

service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary describes what people who used the service and the staff told us, what we observed and the records we looked at. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The home was clean and tidy at the time of our inspection. Staff told us that they had received appropriate training and demonstrated that they were confident about their roles and responsibilities. Staff had access to personal protective equipment (PPE) and were clear about which equipment should be used for which cleaning task. There were facilities around the home to promote good hand hygiene. Domestic staff showed us checklists which listed when areas of the home should be cleaned. This meant that there were systems in place to make sure that all parts of the service were kept hygienic and free from the risk of infection.

We found evidence that the home had taken some steps to ensure that it was compliant with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. More work was needed to further enhance staff understanding of the recent changes in the scope of this legislation.

We found that the home had recruited a number of junior and apprentice staff to work in the home. Staff told us that whilst there were sufficient numbers of staff to support the people accommodated, not all care staff had the necessary skills and experience to do the job.

Is the service effective?

People with lower support needs experienced good outcomes at Thornbury Residential Home. Three people at the home had higher needs. Two people were not being appropriately cared for and were found to be at risk of pressure damage, dehydration and malnutrition. The third person was at risk of social isolation because they were confined to a first floor room without the appropriate equipment to support them to communal areas..

Is the service caring?

This inspection was a follow-up visit and focused on the care of three people with higher dependency needs. People and their relatives all told us that staff were “Kind” to them and that they were “Well looked after.” Our judgment however was that these three people were not well cared for because of the risks they were placed under. For example one person who required two hourly position changes was left unturned for five and a half hours. They subsequently developed a pressure wound and were left in pain. Whilst staff treated people with kindness, their lack of skills and experience in respect of high dependency needs meant that people did not always receive appropriate care.

Is the service responsive?

We again focused on how responsive the home was to people with higher dependency needs. The home had introduced daily charts to monitor people’s food and fluid intake. We found that these were not always fully completed. This meant that the records did not provide an accurate picture of what people had eaten and drank. There was also no system for evaluating the records. This meant that the home could not evidence that these individuals had received sufficient nutrition and hydration. Where people had lost weight or become immobile, no referrals had been made to the appropriate professionals. This meant that the home was not responding to people’s changing needs.

Is the service well-led?

At our last inspection the home’s Statement of Purpose was out of date and this had since been reviewed. In line with our previous compliance action, the home had reviewed its Statement of Purpose. This provided a clearer picture of the services the home was able to provide. The service however had not demonstrated that it was able to meet the needs of all the people accommodated at the home.

The registered manager showed us evidence that they had systems in place that involved people in making decisions about the home, such as menus and activities. There was also an annual quality assurance survey from which stakeholder’s feedback about the home had been evaluated.

Our inspection team was made up of three inspectors, one of whom was a specialist pharmacist inspector. We answered our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary describes what people who used the service and the staff told us, what we observed and the records we looked at. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found the home to be tidy and free from odour at the time of our visit. Two designated cleaners worked in the home for three hours each day. The overall impression of people's bedrooms and communal areas was that the home was clean. On closer inspection however, we found that there was no plan for the cleaning of hard to reach areas and as such some skirting boards, ceilings and window sills were covered in dust and cobwebs. We also found that some of people's equipment, such as walking frames, wheelchairs and commodes had not been recently cleaned.

Staff demonstrated a good understanding of the systems in place by the provider to reduce the risk of the spread of infection and seven of them had attended recent infection control lead training. Staff had access to personal protective equipment, such as gloves and aprons to ensure that they protected themselves and others. There were facilities around the home to promote good hand hygiene. We observed however that some of the home's practices increased the risk of cross contamination, for example mops designated for different areas of the home were stored in the same bucket and the segregation of clean and soiled linen in the laundry was not sufficient to prevent infection spread.

We found evidence that the home had taken some steps to ensure that it was compliant with the Mental Capacity Act and Deprivation of Liberty Safeguards. More work was needed to further enhance staff understanding of the recent changes in the scope of this legislation and although this did not affect any of the people currently living at the home it is something they need to be aware of for the future.

The home had taken appropriate steps to improve the way medicines were managed. Our pharmacist inspector found that the home now had better systems in place to ensure that people received the right medication at the right time. Medicines were now stored in accordance with the law and staff demonstrated safe practices in their handling of people's medication.

We found that staffing levels were insufficient to meet the increased needs of some of the people who lived at the home. This meant that people were placed at risk of unsafe or inappropriate care because there were not enough suitably skilled staff to support all them properly.

Is the service effective?

People with low level needs experienced good outcomes at Thornbury Residential Home. These people were able to move independently around the home with minimal assistance. We saw that they followed their own individual routines and were able to spend their time as they wished. We observed nine people participating in a group quiz during the morning. This session was lively and enthusiastic. We saw that these people were engaging in appropriate activities which they enjoyed and which stimulated them. These people told us that they were "Well looked after" and "Couldn't wish for better."

Four people however, had increased needs and staff spoken with described these individuals as needing "Nursing care". For these people, the care they received at the home was not effective. They were isolated in their own rooms and staff lacked the specialist skills to prevent skin tissue damage and manage their nutritional needs.

Is the service caring?

People told us that staff were "Kind to them" and visitors expressed that the home had a "Really friendly feel." We saw that the majority of people had positive relationships with staff and were supported well by them. For those people with higher needs however, the lack of staff understanding of their needs meant that they did not experience the same good quality of care. We found that three people were alone in their bedrooms for large of parts of the day and staff had not ensured that they had access to their call bells. Two of these people required total support, they requested food and drink, but were told to wait as they had already eaten and drank recently. For these individuals, their experience was not caring.

Is the service responsive?

The home was responsive to people whose needs were low to medium. Staff responded quickly to their requests and had a good understanding of how they liked and needed to be supported. One person told us that they liked to get themselves dressed independently, but that staff would always help them when they needed it. For people with higher needs, the service was more reactive. They relied on the district nursing team to provide the support these people needed because the staff did not have the skills and experience to care for them.

Is the service well-led?

The provider had some systems in place to monitor and improve the services provided. Since the concerns raised by our previous inspections about medication, the provider had introduced a daily medication audit. This additional checking had improved the way medicines were being managed.

We saw that the home held regular residents' meetings and for those that were able to participate, they had an active voice in the running of the home. The registered manager however had failed to listen to the on-going concerns of staff about the needs of some of the people that were not being met at the home. We have asked the service to review its Statement of Purpose and make it clearer to people who use the service what types of care they are able to safely provide.

You can see our judgements on the front page of this report.

We watched people being given their medicines. We spoke to two people at lunchtime who took their medicines and one person told us that the morning medicines are brought round on the breakfast tray.

This was a follow-up inspection by one of our pharmacist inspectors. The last two inspections in September 2012 and July 2013 had identified that medicines were not always managed appropriately by the home. The provider had sent us an action plan stating that they would be compliant from 03 September 2013.

We saw the most people received their medicines as prescribed by their doctor. We found that for one person who was new to the home, the details of medicines prescribed had not been accurately completed on the records. This had meant that staff had not given one of this person's prescribed medicines on the first day.

We also identified concerns with the way medication was being stored and the records maintained about the medicines handled in the home.

We carried out this inspection to assess the improvements that the home had made in respect of care planning, managing medicines and infection control. In response to some feedback we had received, we also looked at the way people were kept safe and the equipment that was available to them.

We spoke with eleven of the people who lived at the home and one relative. People told us that they were happy at the service and said that they were "Treated very well." People spoke highly of staff who they described as "very nice people", "Kind" and who "Really look after us." A visitor said that their relative was "Fantastically well looked after." We saw that most people were able to move around the home independently and as such joined in the daily activities.

We interviewed five members of staff and also spent time with the manager and activities co-ordinator. Staff told us that they had access to appropriate training and equipment to do their jobs. Staff views on the quality of care provided was mixed, although all staff said they thought people were safe at the home.

We found that records about care needs had improved since we last visited. We also identified that the home had taken steps to improve infection control practices. We did however find that medicines were not always being managed safely and in accordance with best practice. We also found that some equipment had not been recently tested and the call bells for two people were not accessible to them.

People told us that Thornbury Residential Home was a nice place to live and that they were “well looked after”. They said that they were “very happy here” and “wouldn’t want to live anywhere else”. People described staff as “really nice”, “kind” and “like angels”. People told us that they felt they were treated well and with respect.

People told us that they were “really well looked after” and that the home was a “really nice place to be”. All people who spoke with us said that staff were “really good” and “kind”. People told us that they were kept “well occupied” and that the “food is lovely”.

We inspected Thornbury Residential Home on 8 and 10 July 2015. Thornbury Residential Home provides accommodation, care and support for up to 19 people. On the day of our inspection 17 older people were living at the home aged between 77 and 97 years. The service provided care and support to people living with diabetes, sensory impairment, risk of falls and long term healthcare needs.

The home is located within close proximity to Uckfield town centre. Many people living at the home have lived there for many years. The provider had good retention of staff, with some staff members having worked there for over five years. Throughout the inspection, people and visitors spoke highly of the home. The service was last inspected in October 2014 where one area was identified as in breach of the regulations. This was related to record keeping. We found the provider had made some improvements however there remained areas that required improvement with record keeping. We also found new additional areas that breached regulations.

A registered manager was in post, who was also the provider/owner. 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 and associated Regulations about how the service is run.

People told us they felt safe living at Thornbury Residential Home however we found the provider had not ensured risks to people’s safety and security had been adequately assessed. The front door to the service was left unlocked during daytime hours and the inspection team gained access to a person’s room without staffs’ knowledge.

Although there were appropriate systems in place for the safe receipt and disposal of medicines we found some concerns with the management of medicines. For example the provider had not sought appropriate professional guidance prior to one person’s medicine being administered in a way that could alter its effectiveness.

Staffs recruitment files were well ordered and contained, identification, employment histories and references however we found one member of staff had not undergone appropriate checks to ensure they were suitable to work in a care setting. There were sufficient numbers of staff working to keep people safe.

People told us they found the home to be clean and tidy however we found areas more difficult to clean such as light fittings and ceiling fans were not clean. One toilet was found to be odorous. The service operated a reduced cleaning programme at the weekend.

The provider ran regular training and refreshers for staff to ensure they had the skills and confidence to support people. However we found one member of care staff whose training was not up-to-date. Staff were not having routine supervision with a senior member of staff from the service. Group and some one to one supervision had been undertaken by an external quality assurance company whom the provider had commissioned. Although the registered manager had oversight of the outputs from these meeting there was no evidence actions had been taken as a result of the issues staff had raised.

People told us staff were kind and we observed positive interactions between people and staff, however we found occasions where people’s dignity had not been promoted. For example people’s care notes and staff’s language.

The service had a range of activities on offer provided by both internal and external providers; people told us they enjoyed these. However we observed people were left at some points during the day whilst staff were engaged with domestic tasks. The provider did not offer activities at the weekend; one person told us they could be bored during these times.

The provider had not routinely submitted statutory notifications to the Care Quality Commission, as required. Under the Health and Social Care Act 2008, providers are required by law to submit notifications of incident affecting people.

Staffing issues identified by an external quality assurance consultant related to staff cohesion and deployment had not been acted upon by the registered manager.

There were some quality assurance processes in place however this had not been effective at identifying the areas of concern we found or driving improvement in the quality of the service.

People’s needs had been assessed and individual care plans were in place. Although care plans had inconsistencies in their layout this had not been identified as an issue by staff. The provider was in the process of introducing new care plans at the time of our inspection. A member of staff told us they were more logical and easier to follow.

Staff had an understanding of the procedures and their responsibilities to safeguard people from abuse. Staff understood their responsibility in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

People were complimentary about the food they received. People had access to a varied menu. If people did not like what was on offer alternatives were available. One person said, “I can always get something I fancy.”

People were supported to maintain good health and had access to on-going healthcare support. People were able to see their GP whenever they needed to. Satisfaction surveys undertaken with health care professionals demonstrated the service liaised effectively with them.

People told us they chose how they spent their time. We saw people freely moving round all areas of the home, relaxing and chatting in friendship groups, reading or watching television. One person told us, “I fill my days as I choose.”

People, staff and visitors were positive about the service and the registered manager. People knew how to raise complaints and concerns and told us they would feel happy to do so if required.

There were a number of breaches of the regulations. You can see what action we told the provider to take at the back of the full version of the report.