This inspection was carried out on 28 June 2018 and 5 July 2018 and was unannounced on the first day and announced on the second day.

Thornton Manor nursing home is a private home that is set in its own grounds and located close to a rural village of Thornton-le-Moors between Ellesmere Port and Chester. The service is based over two floors and is registered to provide nursing and personal care for up to 47 people. At the time of our inspection there were 43 people living at the home.

The home has 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 a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection in January 2017 we found that there were a number of improvements needed in relation to accurate and contemporaneous records and effective auditing procedures. These were a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 Responsive and Well-Led to at least good. The provider sent us an action plan that specified how they would meet the requirements of the identified breaches. During this inspection we found all the required improvements had been made.

This inspection was done to check that improvements had been made to meet the legal requirements planned by the registered provider after our comprehensive inspection in January 2017. One adult social care inspector visited the home and inspected it against all of the five questions we ask about services: is the service Safe, Effective, Caring, Responsive and Well-Led? We found that the registered provider was meeting all of the legal requirements.

Each person living at the home had a care plan and risk assessments in place that reflected their individual assessed needs. People’s needs that related to age, disability, religion or other protected characteristics were considered three out the assessment and care planning process. Care plans included clear guidance to staff that ensured people’s needs were appropriately met. Staff were knowledgeable about people’s individual needs and histories. Essential records that included repositioning charts and well-being checks were consistently completed and reviewed regularly by the management team. When required end-of-life care plans were in place and people’s expressed wishes were clearly documented.

Effective audit systems were in place that were consistently completed. Areas for development and improvement were identified where required and action plans were prepared and completed. Accidents and incidents were analysed to identify trends and patterns within the service.

Recruitment systems at the service were safe and robust. Sufficient staff were employed to meet the assessed needs of people living at the home. All staff had undertaken an induction and had completed mandatory training in accordance with best practice guidelines. Additional completed training had included managing cardiac arrest and dementia which supported staff to meet the needs of the people living at the home. Staff were supported by the management team through supervision, team meetings and departmental meetings. Staff told us that they felt well supported.

Safeguarding policies and procedures were in place and staff were familiar with these. Staff were able to describe what abuse may look like and felt confident to raise any concerns and thought they would be listened to.

The registered provider had medicines policies and procedures in place. Medicines were ordered, stored, administered and disposed of in accordance with best practice guidelines. Staff the administered medicines ha

This inspection was carried out on 6 December 2016 and was unannounced.

Thornton Manor nursing home is a private home that is set in its own grounds and located close to the rural village of Thornton-Le-Moors between Ellesmere Port and Chester. The service is based over two floors and is registered to provide nursing and personal care for up to forty seven people. At the time of our inspection there were forty one people living at the service.

There was a registered manager that had oversight of the whole service. 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.

At the last inspection on 28 and 29 July 2016 we found that a number of improvements were needed in relation to people not being protected from the risk of unsafe, restrictive care and treatment as well as poor management of infection control. People were not always supported or treated in a dignified way and consent to care and treatment was not always sought. People were not protected from the risk of receiving inadequate care as the quality assurance systems were not effective. We asked the registered provider to take action to address these areas.

After the inspection, the registered provider wrote to us to say what they would do to meet legal requirements in relation to the breaches identified. They informed us they would meet all the relevant legal requirements by November 2016. This inspection found that improvements had been made. Whilst we found improvements in most areas, the registered provider had not demonstrated full compliance with the Health and Social Care Act 2008 (regulated activities) 2014. You can see what action we have told the provider to take at the end of this report.

The registered provider had introduced a number of quality assurance audits since our last inspection visit. Further improvements were needed to make sure that they were effectively used in accordance with the registered providers own timescales to ensure the quality and safety of the care provided to people. Information relating to fluid intake in supplementary records was not always analysed and used to prevent the risk of dehydration.

Staff were able to describe the care and support people required. Daily records were completed in detail to reflect what care and support people had received on a daily basis. Care plans that had been reviewed since our last visit contained up to date, personalised information relating to the health and care needs of each person supported. However, we found that some care plans were task orientated and had limited information about how a person preferred their care and support to be delivered. This meant that people could experience care that was not in line with their wishes, needs and preferences if supported by staff less familiar with them.

People were safe. Staff understood what is meant by abuse and the different forms it can take. Staff knew the process for reporting any concerns they had and for ensuring people were protected from abuse. Staff told us they would not hesitate to raise concerns and they felt confident that they would be dealt with appropriately.

People were provided with appropriate dietary options. During meal times people received appropriate levels of support from staff. People made positive comments about the quality of the food available. However, the mealtime experience required further improvements to be made. This had been recognised and was being addressed by the registered provider.

People received support with their medication. Records relating to the management of medication were up to date and accurate. Care plans relating to PRN (as required) medication were in place. They provided clear written guidance for sta

This inspection was carried out on the 28 and 29 July 2016 and was unannounced.

Thornton Manor nursing home is a private home that is set in its own grounds and located close to the rural village of Thornton –Le-Moors between Ellesmere Port and Chester. The service is based over two floors and is registered to provide nursing and personal care for up to forty seven people. At the time of our inspection there were forty four people living at the service.

There was a registered manager in post at the service since 2011. 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 inspection on 5 January 2016 we found that a number of improvements were needed at the service. These were in relation to the failure to assess and mitigate risks to people, poor management of infection control and cleanliness, a failure to ensure that people were always treated with dignity and respect and failing to ensure records were personalised. Following our inspection the registered provider wrote to us and informed us they would meet all the relevant legal requirements by the end of May 2016.

We also issued the registered provider and registered manager with a warning notice as records did not accurately reflect the care and support people required and quality assurance systems were not robust. We instructed both parties to meet all relevant legal requirements by 13 May 2016.

During our inspection we found that the registered provider had not demonstrated full compliance with the Health and Social care Act 2008 (regulated activities) 2014. We found that improvements had not been sustained and the registered provider was not meeting legal requirements. We identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. CQC are now considering the appropriate regulatory response to the concerns we found. We will publish the actions we have taken at a later date.

People told us that they felt safe living at the service. Staff had an understanding of different types of abuse, how to safeguard people from abuse and how and who to report concerns too. However, areas we had previously raised relating to poor practice, institutional and restrictive practices had not been identified or addressed at the service. During our visit we asked a senior staff member to raise areas of concern we found to the local authority safeguarding team.

The service was not clean. Several areas across the building, including bathrooms were dirty. Equipment, fixtures and fittings were rusty, dirty or in need of repair, replacement or deep cleaning. Carpets and flooring in several areas of the home had an unpleasant smell or required replacing due to wear, tear and damage. Coats worn to access the kitchen for infection control reasons were dirty and stained. The management of infection control was poor.

Sufficient checks were not made on pressure relieving equipment. Sixteen people used pressure relieving mattresses and we found that the settings for seven people were incorrect. One pressure mattress was unplugged from the power and this had not been identified by staff. Care plans did not evidence the correct pressure levels required for individuals. People were at an increased risk of developing pressure ulcers.

Risks to people’s health and safety were not always identified. Where people had experienced significant weight loss or refused treatment for the management of diabetes staff had failed to access support and advice from relevant health professionals to minimise any further risks. Care plans failed to identify the specific equipment people required to support them with their mobility.

People received their medication as prescribed. People’s medication adm

This inspection was carried out on the 5 January 2016 and was unannounced.

Thornton Manor nursing home is a private home that is set in its own grounds and located close to the rural village of Thornton –Le-Moors between Ellesmere Port and Chester. The service is based over two floors and is registered to provide nursing and personal care for up to forty seven people. At the time of our inspection there were forty four people living at the service.

At the last inspection on 10 February 2015 we found that there were a number of improvements needed in relation to: Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), security of records and the safe storage and use of equipment. We asked the registered provider to take action to make a number of improvements. After the inspection, the registered provider wrote to us to say what they would do to meet legal requirements in relation to the breaches identified. They informed us they would meet all the relevant legal requirements by the 30 May 2015. However, whilst the registered provider has made some improvements, they had not fully addressed all of the actions outlined in their own action plan. We found a number of breaches and two continued breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we have told the provider to take at the end of the report.

The service has 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.

People told us they felt safe at the service. Relatives told us that they were reassured that when they left to go home their loved ones would be cared for and protected from harm. Staff knew the process for reporting any concerns they had and for ensuring people were protected from abuse. Staff told us they would not hesitate to raise concerns. The registered provider has systems in place to ensure that safeguarding incidents and complaints were reported to the relevant authorities.

We saw that bedrooms and communal areas on the ground floor were clean and tidy. However we found that areas on the first floor of the service were not clean. Several areas were dirty and in need of a deep clean. The management of infection control and corresponding records required improvements to be made.

The registered manager and staff showed a basic understanding of their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The registered provider did have policy and procedures in place with regards to the MCA. We found that the registered manager had made some applications to the supervisory body under Deprivation of Liberty Safeguards, but supporting documentation did not reflect how complex specific decisions for people who may lack capacity had been made. This meant that decisions may not always have been made in conjunction with people whilst considering their best interests.

Whilst we saw that people on the ground floor enjoyed mealtimes in a dignified manner this was not the case for the people on the first floor. The mealtime experience on the first floor did not promote a positive experience for people. Undignified practice such as putting plastic aprons on everyone was observed. Staff did not always ask for people’s opinions or offer choices at mealtime. People were not always treated with dignity and respect.

Staff attended regular training sessions in areas such as moving and handling, first aid and safeguarding adults to update their knowledge and skills. Staff have had regular meetings and supervisions to discuss areas of improvement in their work. Staff told us that the management team were making lots of positive improve

The inspection took place on 10 February 2015 and was unannounced. This meant that the provider did not know that we were coming. We last inspected this location on 14 February 2014 and at that time it met the regulations.

Thornton Manor provides nursing and personal care for up to forty seven people with physical illness and /or dementia. At the time of the inspection there were 41 people living at the location. The accommodation is provided on two floors. The home is set in its own grounds in a rural location between Ellesmere Port and Chester.

There was a registered manager in place. 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.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.This was replaced on 1 April 2015 by the Health and Social Care Act 2008(Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report

People and their relatives were positive about the home and the care that was received. They told us that staff were” kind”, “patient” and they “liked them”.” We saw that staff did not rush people and took the time to talk and chat. We also saw that there was lots of activity to keep people occupied and stimulated. We found that not everyone was aware of the complaints policy and it was inaccurate and up to date. Relatives told us that staff and the registered manager were approachable and they could go to them if they were worried. We saw that a survey had been sent out recently to seek the opinion of those using and visiting the service

Staff knew the people they were supporting and provided a personalised service. Care plans were in place and detailed how people wished to be supported in terms of choice. However, these weren’t always legible, up to date or reviewed. This meant that people may not get the right care from someone who did provide care to them regularity. We saw that staff, who spoke with us, on the day, understood the care that people needed and encouraged them to do things for themselves. We found that records about people were not stored securely and therefore information about people was not kept confidential.

Where people were able, they were involved in making decisions about their care. Relatives also told us that they were involved and consulted. When a person lacked the capacity to make a specific decision, staff did not always take into consideration the Mental Capacity Act 2005(MCA). For example, staff asked relatives to make decisions without any evidence that they had legal authority to do so. The Deprivation of Liberty Safeguards was not always considered where applicable. (This is where an application can be made to lawfully deprive a person of their liberties where it is deemed to be in their best interests or for their own safety.) For example, the provider had not considered applications for a number of people, even though their liberty was being significantly restricted by them not being able to leave a secure environment of their own accord.

We saw that people lived in an environment that was clean but in need of some refurbishment and decoration. We identified concerns about the safety and suitability of equipment within the home that placed people at risk. We saw, for example, that equipment required in the event of someone having a cardiac arrest was not fit for purpose.

People received care from staff that had been through the appropriate recruitment processes to ensure that they were suitable to work in the care sector. Staff had also received training and ongoing support in order to support them to carry out their jobs effectively. We did, however, see that the policies and procedures, put in to support and guide staff were not kept up to date. The registered person should set out to Care Quality Commission, in a statement of purpose, its aims and objectives of the service and ensure that this is kept under review. We found that this had not been reviewed since 2009.

We carried out this inspection because at our previous inspection in July 2013 we had found that the registered provider was not meeting all of the essential standards for quality and safety.

At this inspection we found that there were systems in place to gain and review consent from people who used the service and best interests meetings were held for those who did not have the mental capacity to give informed consent.

The people who used the service and relatives we spoke with said that generally they were happy with the care provided. One person who had been at Thornton Manor for three years said "It's nice here, they look after me". Another said "It's alright here. The staff are lovely, I get on well with them". Staff were aware of the needs of the people who used the service and we observed that staff were pleasant and respectful in all their interactions.

People were less complimentary about the food. Most people said the food was "alright" or "ok", but a couple of people we spoke with said they didn't enjoy the food and we noticed there was a lot of food left on plates at lunchtime. However, people were offered choices and supported to eat and drink if necessary. People were weighed regularly and no-one was losing any weight.

Some redecoration had recently taken place and new curtains and duvet covers had been purchased.

There were adequate systems in place to monitor the quality of the service and identify and manage risks.

A number of people who used the service were unable to verbally communicate their views and although we spoke with several people we were unable to engage with them in a meaningful way. We used a number of different methods to help us understand their experiences. We spoke to relatives, looked at records, spoke to staff and made observations of the support provided.

We spoke to one person who used the service who said they were happy living at the service. We spoke to five relatives who were also happy with the care and support provided. Some comments made were: -

“The staff really care. They are very good with my mum.”

“It’s a very good place. I would recommend it to others.”

We found that a number of improvements were needed to the service to ensure that people were provided with safe care and treatment that met their needs and protected their rights.

We found that improvements were needed to care planning and care delivery and to the practices in place to demonstrate people's needs were met when they were not able to give their consent to care and treatment.

We found that peope were not adequately protected against the risks of inadequate nutrition.

Improvements’ were also needed to the system in place to identify, assess and manage risks to the health, safety and welfare of the people who used the service.

An expert by experience accompanied us on this visit. They found the staff to be respectful and friendly towards the people who used the service. They considered that people’s needs were being met to a good standard. They identified some areas where improvements could be made to the home environment and equipment being used.

We spoke to five people who used the service who were happy with the care and support provided by staff. Some comments made were:-

“This is the best care ever.”

“ Everyone is friendly. We are happy here.”

We spoke to three relatives who were also happy with the care provided by staff. Some comments made were: -

“I have full confidence in all the staff. My relative is very well cared for. If they become ill, staff ring me.”

“I am extremely pleased with this home, the staff are polite and friendly, first class. I am always included in consultations between the doctor, and senior staff.”

The manager had sent surveys to the people who used the service and their relatives within the last six months to find out their views about how the service was operating. The thirteen responses had been mainly completed by relatives. The responses were positive. They indicated that people felt involved in the care provided, had their needs met and were satisfied with the service.

We asked the commissioners of the service and the local safeguarding co-ordinator for their views. Three concerns had been raised about the home to Cheshire West and Chester Social Services within the last twelve months. There was no information to suggest that two of these concerns had any basis and additional training for staff was the recommendation from the investigation into the third issue raised. Training records showed that the manager was addressing this matter.

We spoke to a health professional and a social care professional who were regular visitors to the service. They said that a good standard of care was provided. There was good communication with the staff and they always contacted them appropriately when a person needed their help. They said that the staff knew the needs of the people who used the service well and managed the needs of people with dementia well.

A report from a visit made by the Cheshire West and Chester Local Involvement Network (LINKs*) in May 2012 indicated that staff interacted well with the people who used the service. The report indicated that there was a good atmosphere within the home and some of the people they were able to speak with said they were happy living at the home.

The LINKs report indicated that residents’ rooms appeared to be well furnished and decorated. The report indicated that some improvements to the home environment were needed.

* LINKs are networks of individuals and organisations that have an interest in improving health and social care services. They are independent of the council, NHS and other service providers. LINks aim to involve local people in the planning and delivery of services.