This inspection took place on 2 and 5 July 2018. The first day of the inspection was unannounced. This meant the staff and provider did not know we would be visiting.

Thorncliffe House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Thorncliffe House accommodates 24 people with personal care needs in one adapted building. Some of the people were living with dementia. On the day of our inspection there were 20 people using the service.

The service had a registered manager in place. A registered manager is a person who has registered with CQC to manage the service. Like 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.

Thorncliffe House was last inspected by CQC in June 2017 and was rated Requires Improvement. At the inspection in June 2017 we identified the following breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 9 (Person-centred care) and Regulation 17 (Good governance). 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 of Safe, Responsive and Well-led to at least good. At this inspection we found improvements had been made in all the areas identified at the previous inspection and the service was now rated Good.

Accidents and incidents were appropriately recorded and investigated. Risk assessments were in place for people who used the service and described potential risks and the safeguards in place to mitigate these risks. The registered manager understood their responsibilities with regard to safeguarding and staff had been trained in safeguarding vulnerable adults.

Medicines were stored safely and securely, and procedures were in place to ensure people received medicines as prescribed.

The home was clean, spacious and suitable for the people who used the service. Appropriate health and safety checks had been carried out.

There were sufficient numbers of staff on duty in order to meet the needs of people who used the service. The provider had an effective recruitment and selection procedure in place and carried out relevant vetting checks when they employed staff. Staff were supported in their role via appropriate training and regular supervisions.

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 supported this practice.

People were appropriately supported with their health and dietary care needs.

People who used the service and family members were complimentary about the standard of care at Thorncliffe House. Staff treated people with dignity and respect and helped to maintain people’s independence by encouraging them to care for themselves where possible.

Care records showed that people’s needs were assessed before they started using the service and support plans were written in a person-centred way. Person-centred is about ensuring the person is at the centre of any care or support plans and their individual wishes, needs and choices are taken into account.

People were protected from social isolation and the service had good links with the local community.

People who used the service and family members were aware of how to make a complaint. The provider had an effective quality assurance process in place. People who used the service, family members and staff were regularly consulted about the quality of the service via meetings and surveys.

This inspection took place on 18 and 21 April 2017. The first day of the inspection was unannounced. This meant the provider and registered manager did not know we would be visiting.

Thorncliffe House provides personal care and accommodation for 24 older people. The service was supporting 16 people at the time of this inspection. Some people were living with dementia.

The service had a registered manager. 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.

During this inspection we found the registered provider had breached two regulations of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014

You can see what action we have asked the provider to take at the end of this report.

At the previous inspection we found care plans did not always contain up to date information. During this inspection we again found care plans were not always up to date. Where people were recorded as needing additional safety checks, no records were maintained to demonstrate checks were made. Risk assessments were in place for people; however some risk assessments were not recorded accurately.

The registered provider had a quality assurance matrix in place to ensure that audits were carried out on a regular basis. The quality assurance audits at this inspection had not identified the concerns we found in relation to record keeping.

The provider did not have evidence to demonstrate how the audit process was used to develop the service. No overall action plan was available to record managerial review and monitoring of the service to drive improvement.

Medicines were administered by trained staff who had their competencies to administer medicines checked regularly. Medicine administration records (MAR) were completed with no gaps and medicine audits were completed regularly. Policies and procedures were in place for safe handling of medicines for staff to refer to for information and guidance. The provider had not copied people’s medicine care plans regarding ‘as and when’ medicines to sit alongside their MAR as per the provider’s medicine policy.

The registered provider used a dependency tool to ascertain staffing levels. We found staffing levels to be appropriate to needs of the service, these were reviewed regularly to ensure safe levels. Staff were visible throughout the building during both inspection days.

There were robust recruitment processes in place with all necessary checks completed before staff commenced employment.

There were systems in place to keep people safe. We found staff were aware of safeguarding processes and how to raise concerns if they felt people were at risk of abuse or poor practice. Accidents and incidents were recorded and monitored as part of the registered manager’s audit process.

Staff training was up to date. Staff received regular supervision and an annual appraisal. Opportunities were available for staff to discuss performance and development.

People were supported by kind and attentive staff who clearly knew people well. Staff discussed care interventions with people before providing support. Advocacy services were advertised in the foyer of the service and were accessible to people and visitors. Staff knew people's abilities and preferences, and were knowledgeable about how to communicate with people.

People’s nutritional needs were assessed and we observed people enjoying a varied diet, with choices offered and alternatives available. Staff supported people with eating and drinking in a safe, dignified and respectful manner.

People were supported to maintain good health and had access to healthcare professionals when necessary and were supported with health and well-being appointments.

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This inspection took place on 4 May 2016 and was unannounced. We last inspected Thorncliffe House on 1 and 3 September 2015 and found the provider had breached a number of regulations we inspected against. Specifically the provider had breached Regulations 12, 17, 11, 13 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not have effective systems in place to ensure medicines were ordered, stored and administered safely. There was not an effective quality assurance process to monitor the quality and safety of the service provided to ensure people received appropriate care and support. Consent had not been gained in respect of locking people’s rooms. The provider had failed to investigate concerns in relation to safeguarding people immediately upon becoming aware of allegations or evidence of abuse. The provider had not ensured staff received appropriate training and development to enable them to carry out the duties they were employed to perform.

We undertook this inspection to check they now met legal requirements. During this inspection we found that the registered provider had implemented actions and some improvements had been made.

Thorncliffe House is a care home without nursing and provides accommodation and personal care for up to 24 people, some of whom may be living with dementia. At the time of the inspection there were 19 people using the service.

An established registered manager was in post and registered with the Care Quality Commission at the time of the inspection.

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.

Quality assurance systems and audits had been introduced but it was too early to assess whether they were effective in driving continuous improvement. Required actions were not always recorded, and when actions were documented it was not always evident if they had been completed or not.

Medicines were ordered and stored in a safe way. There were some gaps in the recording of the administration of medicines but these had been identified by the deputy manager.

Personal emergency evacuation plans had been introduced however they were not accurate and contained out of date information in relation to the rooms people lived in.

Deprivation liberty safeguards had been authorised and we saw evidence of mental capacity assessments and best interest decision making. Best interest decisions did not always evidence consultation with family members or professionals.

Activities were available for people but they were not well advertised and there were no specific activities for people living with dementia.

Systems had been introduced for the recording and investigation of safeguarding concerns, accidents and incidents.

Staff had received the training they needed to support them to care for people appropriately. They received regular support and team meetings were held quarterly. Minutes of meetings were not readily available for staff.

Recruitment procedures were in place however one person had commenced in post without the registered manager having received a reference from the previous employer. This was acted on immediately and we saw a satisfactory reference was received on the day of the inspection.

We observed warm and caring interactions between staff and people. Staff afforded people the time they needed and did not rush people in any way. They respected their privacy, dignity and helped to maintain independence when possible.

Information on advocacy and how to complain or provide feedback was available for people and visitors.

This report identifies Margaret Kirkwood as the registered manager she is no longer in post and is being removed from the register. We carried out an inspection in June 2013 and found improvements were needed. People were not protected from the risk of infection, and appropriate records were not maintained. The provider sent us an action plan outlining the steps they would take to address these shortfalls and at this visit we looked at what improvements had been made.

The service was visibly cleaner, it was tidy and odour free.The manager showed us cleaning schedules used and told us she checked to ensure they were followed. Additional domestic staff had been appointed. The manager said she was confident checks and audits would identify areas were maintained to acceptable standards. Areas such as the bathrooms and toilets had been deep cleaned and some areas had been redecorated. For example one had wallpaper removed and replaced with impervious cleanable material. Staff had received infection control training and were following good practice guidance. People were protected from the risk of infection because appropriate guidance was being followed.

Care plans were up to date, more detailed and specific to the persons needs, they were in the process of being changed over to a new format so were of varying degree of completion. They contained enough information to ensure staff could deliver appropriate safe care, for example detailed moving and handling information.

Those people we spoke with said they were happy with the service provided by the staff. One told us she thought the service was "Really nice" and was "Happy to be here". Another said “The girls are lovely, and they all treat me the same, I don’t have any favourites and neither do they”.

People told us they were given enough information regarding their care or treatment. None moved into the home without having had their personal needs assessed and explained to them. People told us they were treated with respect at all times and said staff “Listened to them”.

There were processes for dealing with allegations of abuse and local authority safeguarding adults guidance was available for the staff to refer to. Not all staff had received training in recognising abuse and how to report concerns; however training was planned to address this. The manager was developing the training programme and this training was also part of the ongoing plan for updating all training.

People were not protected from the risk of infection because appropriate guidance had not been followed. There was a risk of cross infection caused by unacceptable cleaning procedures and some poor care practices.

Care plan documentation was not up to date and in sufficient detail to reflect peoples complex needs, individual preferences and choices. This meant that the staff did not always have enough information to ensure that the care they were giving would fully meet people’s needs and keep them safe.

This inspection was a themed inspection focussing on dignity and nutrition. People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an “Expert by Experience”; people who have experience of using services and who can provide that perspective and also joined by a Practising Professional.

To help us to understand the experiences people have we used our Short Observational Framework for Inspection (SOFI) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences.

We did a SOFI observation of the lunch time meal in the main dining room. It was evident carers and people who used services interacted very well with each other. Carers and nurses ensured people were able to contribute to choosing what they wanted to eat. All people were given the opportunity to voice their views and opinions and staff assisted people sensitively and at a pace suitable to the individual.

During this themed inspection visit, we spoke to eight people who used the service and two relatives. This is what they told us: People who used the service said they were given appropriate information and support regarding their care and treatment. Each person had a written contract and a statement of their terms and conditions with the provider. No-one had moved into the home without having had their personal needs assessed. They had been assured by the senior staff these needs would be met.

People told us they had been involved and had contributed to the pre-admission assessment. People told us their privacy and dignity was upheld by staff working in the home.

The people we spoke with said they had a choice of at least three hot meals each day. People said portion sizes were good. They said second helpings were always available if they wanted more.

One person said “We get three large meals each day and we are offered finger snacks between meals. I always enjoy the meals, the cook knows exactly what I like and dislike and the food is always very good.”

Another person told us “We are always offered a choice of options for every meal. I love having a cooked breakfast everyday. If we don’t like the options offered, the cook will prepare something else. I have no complaints at all about the meals.”

People told us they felt safe living here. They said they could express themselves freely and without fear. People told us they would know who to speak to if they had any concerns. People also told us they were well supported by the staff team and were happy with the care, treatment and support they received.

People told us they were treated with respect at all times and said staff listened to their views and these were acted upon ”.

We spoke with two visitors. They told us the care their relatives received was exceptional. They said staff were very knowledgeable about their relatives support needs. Both told us the staff were very good at keeping them informed about their relative’s health and wellbeing. One described how their relative had been supported by the staff to lose weight. They said a healthy eating plan was introduced with great success.

This inspection took place on 1 September 2015 and was unannounced. This meant the provider did not know we would be visiting. A second day of the inspection took place on 3 September and was announced. We last inspected the service in October 2013 and found the provider was meeting the regulations we inspected against at that time.

Thorncliffe House is registered to provide accommodation and personal care for up to 24 people, including some people who were living with dementia. At the time of our inspection there were 20 people using the service.

The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (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.

During this inspection we found the provider had breached a number of regulations. Procedures for managing people’s medicines were not safe. The provider did not have effective systems in place to ensure that medicines had been ordered, stored and administered. We noted safeguarding concerns were not investigated by the provider. We also found the provider did not ensure staff received appropriate training and development to enable them to carry out the duties they were employed to perform. We found people using the service did not have access to keys to their own rooms. We also found that the provider did not have effective quality assurance processes to monitor the quality and safety of the service provided and to ensure that people received appropriate care and support.

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

Risk assessments were completed individually for people within the home based upon their needs. For example, one person’s risk assessment indicated they had elected not to have thickener added to their fluids.

The provider completed reference checks and a Disclosure and Barring Service (DBS) check prior to employees starting work.

During our tour of all bedrooms in the home we noted none of the wardrobes were fixed to the wall to prevent any accidental injuries to people.

The five year electrical installation report was not available at the time of our inspection.

The provider did not have a personal emergency evacuation procedure in place.

We noted staff had received three supervisions since the beginning of the year. We saw these were conducted in group supervision. We saw three out of 26 staff had received appraisals

When required people were supported to have specialist or modified diets. The chef was able to describe the specialist diets of individual people.

We saw evidence in care plans of cooperation between care staff and external healthcare professionals including community nurses, occupational therapists, and GPs to ensure people received effective care.

People seemed happy and comfortable with staff. One person told us, “They look after me well.” Another said, “They are good.”

We noted large amounts of continence pads stored in a number of bedrooms. We questioned the appropriateness of storing such items and the impact of a person’s self-esteem and dignity.

We noticed when the home was at its maximum staffing levels there were positive interaction between care workers and people using the service. However later in the day when staffing was reduced to one senior and two carer workers interactions were limited.

All care plans were comprehensive and included communication, continence needs, washing and dressing, activities, religious beliefs and medication.

Staff we spoke with said they were happy in their work. They also said they felt supported in their roles by management. Staff said the home had a good atmosphere.

People who used the service and their family members had the opportunity to give their views about the service.

The overall rating for this service is ‘inadequate’ and the service is therefore in ‘Special Measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.