Thistle Hill Care Centre is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

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 ga

This inspection took place on 8 March 2017 and was unannounced. This meant the registered provider and staff did not know we would be visiting the service. A further two days of inspection took place on 13 and 15 March and these were announced.

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 h

This inspection of Thistle Hill took place on 26 and 27 July 2016 and was unannounced. The inspection was carried out in response to some serious concerns we had received regarding the care and support provided at Thistle Hill. An investigation into these concerns is underway and we will report on any action once completed.

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 pl

This inspection took place on 5 November 2015 and was unannounced. The last inspection at this service was on 17 November 2014 and at that inspection we found a breach of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to three regulations: Regulation 22 HSCA 2008 (RA) Regulations 2010 - Staffing. The provider had failed to protect people against the risks associated with not maintaining appropriate staffing levels. Regulation 10 HSCA 2008 (RA) Regulations 2010 - Assessing and monitoring the quality of service. The provider had failed to protect people from unsafe and inappropriate care and to promote people and their representatives to express their views or in relation to making complaints. And Regulation 17 HSCA 2008 (RA) Regulations 2010 - Respecting and involving people who use services. The provider had failed to treat people with consideration and respect and encourage and support people in relation to promoting their autonomy. The overall rating for the service at that time was ‘Requires Improvement.’ At this inspection we found that improvements had been made to address the shortfalls. However, for one of the units the leadership and guidance provided for staff needed to improve in order that current practice could be consolidated and more effective. It was also of concern that staff were not adhering to confidentiality procedures and this needs to be addressed by the provider.

Thistle Hill Care Home is registered to provide nursing care for up to 85 people. The home is owned by Barchester Health Care Homes Limited and is located on the outskirts of Knaresborough, a market town. The home is divided into three units. One unit is for people who are living with dementia, one is for older people who require general nursing and the third unit provides care for younger adults with disabilities. All rooms are single with en-suite facilities. There is a passenger lift to access upper floors and there is parking available on site.

There was a registered manager at this service who has been employed at the home for over eight years. 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. However, at the time of our inspection the registered manager was unavailable. The operations manager and acting regional director were on site during the inspection and provided all the information we asked for.

In the main, people told us they felt safe and we saw that risks had been identified within the service and actions taken to ensure peoples safety. Medicines were managed safely and people received their medication as prescribed and in accordance with their medical conditions.

Staff understood how to protect people from abuse and had received training. They were supported to do this by senior led supervision and staff meetings, which were formal and informally arranged. However, we identified that more frequent senior management input was required to one of the three units to make sure that any issues raised by staff during their working shift could be addressed promptly.

The majority of people who used the service had care and support plans which were personalised and they had been involved in the development of these. People were involved in all aspects of their care as far as possible, depending on their individual needs.

People knew who to complain to and complaints were being dealt with as described in the providers procedures.

There was an effective quality assurance system in place at this service. The service had a dedicated training officer who planned the training calendar to make sure staff complete the required training and remain up to date and skilled.

Health and safety risks had been considered and actions had been taken to minimise them.

Overall care plans were personalised and any risks had been identified. Care plans contained sufficient detail so that staff could meet peoples needs appropriately. This was essential as some staff working at the service were from local agencies and did not necessarily have any prior knowledge about the people they were supporting and providing care to.

People had access to a wide range of activities which were age appropriate and reflected their interests and preferences.

Some people were not able to tell us about their experiences. We therefore used a number of different methods to help us understand the experiences of people. This included observing the delivery of care and speaking to visitors as well as people who lived at Thistle Hill.

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 were not able to communicate with all of the people living at the home due to their complex communication needs. We did however see people were very comfortable and at ease with the staff team when anyone approached them. Staff recognised and understood people’s needs and used gestures and touch, when necessary, to reassure and comfort people.

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.

People told us they were 'more than happy' living at Thistle Hill. They said they 'liked' the staff and that they were given everything they needed. People also said they were treated 'well and with respect'. Visitors told us about meetings in the home, where they could meet the manager and staff and discuss topics which impacted on their relatives. They also said they felt their relative was treated with respect. One visitor said their relative was, “So well looked after and loved." People said they can voice their views about their treatment and care and that staff included them in whatever decisions were being made.

People told us that they thought there were, ‘enough’ staff around, to make sure they were cared for properly. One person said, “The staff always come to you when you need help”. Some visitors said that they called into the home at different times of the day and although staff always seemed busy, they could always get attention if it was required. They did not report any delays when using the nurse call system.

People who were able told us they could make choices about aspects of their lives, about rising and retiring, where to sit, what activities to participate in and what clothes they wished to wear.

People who were able told us they had seen their care plan and agreed to the contents. They said they saw a range of health care professionals.

People said they liked the meals provided and the chef was able to meet personal requests for alternatives to the menu.

People were complimentary about the staff team, ‘They always go at my speed’, ‘Nothing is too much trouble’ and ‘Very caring and understanding’. One person did state that staff members from an agency were used sometimes and, ‘they seem lost at what to do’. They also said that this could be an issue for them, ‘I like staff to know my needs as communication is very, very difficult’.

This inspection was carried out on 27 November 2014 and was unannounced. We also returned on the 1 December 2014 to complete the inspection. At our last visit to Thistle Hill Nursing Home in December 2013 we did not ask for any improvements to be made.

Thistle Hill Care Home is registered to provide nursing care for up to 85 people. The home is owned by the Barchester Health Care Homes Limited and is located on the outskirts of Knaresborough market town. The home is divided into three units. One unit for people with dementia care needs (Memory Lane), one for older people who require nursing (Ripley) and the third provides care for young adults with disabilities (Farnham). All rooms are single with en-suite facilities and there are a range of outside spaces.

There was a registered manager at this service who has been at the home for over seven years. 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 had mixed views and responses from people living at the home when asked if they felt safe. Some people told us they felt safe at the home whilst other people raised concerns with us about staffing levels and care practices.

People living at the home received care and support from well trained staff on Memory Lane, whilst on Ripley and Farnham the support people received was poor. For example people were unable to go to the toilet when they needed or to have a shower when they wanted one. People also told us that call bells were not always answered promptly. We found that there were not always sufficient staff on duty, to meet people’s care needs and to care for people well. This is a breach of Regulation 22 (Staffing), of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We observed interactions between staff and people living in the three units. We saw at times interactions and communication between people living at the home and members of some staff were poor. We observed lunch and saw that this was not always a pleasurable experience for people who required support with their meals.For example we saw on one unit a member of staff balancing a hot plate of food on the wheelchair arm which could have been a potential health and safety hazard as the person could have been put at risk of being scalded. We saw people’s privacy and dignity was not always respected by some staff, as we observed staff not knocking on people’s doors before entering their rooms. We found people were not protected from unsafe and inappropriate care. The home did not encourage people and their representatives to express their views or to make a complaint. This is a breach of Regulation 10 (Assessing and monitoring the quality of service provision) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Several people living at the home and their relatives told us they were not consulted or encouraged to share their views about the home. People told us they felt they were not listened to and when they did share their views these were not acted upon. They also said they did not find the culture at the home was ‘open’. Several people we spoke with and some relatives told us they were worried about there being repercussions because of speaking with us. We found that the home had failed to treat people with consideration and respect and encourage and support people in relation to promoting their autonomy. This is a breach of Regulation 17 (Respecting and involving service users) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

We saw that regular checks to ensure that safety equipment such as the fire alarm system were in good working order were regularly being carried out, which meant that there were systems and processes in place to protect people from the risk of harm.

The home had safe systems in place to ensure people living at the home received their medication as prescribed; this included regular auditing by the home.

There were good systems in place to minimise the risk of infection which were followed by staff working at the home.

The recruitment processes followed by the organisation when employing staff were robust, which meant that people were kept safe.

Staff had completed all mandatory training and had received supervision and annual appraisals.

People who were unable to make their own decisions were protected because staff followed the principles of the Mental Capacity Act 2005 and associated deprivation of liberty safeguards.

Staff understood how to apply for an authorisation to deprive someone of their liberty if this was necessary.

People’s physical health was monitored as required. This included the monitoring of people’s health conditions and symptoms so appropriate referrals to health professionals could be made.

The home’s environment was well maintained and the design and layout supported people to be independent and met their needs well.

We contacted other agencies such as the local authority commissioners, from the Local Authority and Healthwatch to ask for their views and to ask if they had any concerns about the home. Feedback from all of the agencies we contacted were positive with no concerns being raised.