This inspection took place on 21 June 2016. The inspection was unannounced. An unannounced inspection is where we visit the service without telling the registered persons we are visiting.

Thornhill House is a residential care home registered to accommodate 35 older people. At the time of the inspection 31 people were living at the home. The home is operated as two units, one for people requiring rehabilitation, with the intention of returning home and one for people who have personal care needs, some of whom are 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 and associated Regulations about how the service is run.

Feedback from people, relatives, staff and other stakeholders was that the manager provided effective leadership to the service and held regular meetings with people and staff to ensure all relevant stakeholders had an opportunity to express their opinions on the quality of the service provided and the running of the home.

Since 9 July 2013 Care Quality Commission inspectors have carried out five inspections and have found a history of breaches with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. At the inspection on 1 and 3 December 2015 a warning notice was issued for the regulation associated with good governance. At this inspection we checked and found that improvements had been made to meet the regulation. The service must now demonstrate they can consistently meet the regulation and demonstrate continuity in a well led service.

When we spoke with people who used the service they all told us they felt safe. Relatives spoken with did not raise any concerns about mistreatment or inappropriate care provision of their family member. Staff had received safeguarding training and were confident the manager would act on any concerns.

We found staffing levels were sufficient to meet people’s needs and the recruitment of staff included all the relevant information and documents required to ensure staff were suitable to work with vulnerable people.

Systems and processes were in place for the safe administration of medicines.

Systems were in place to manage risks to people and the service to ensure people, others and the environment were safe.

Staff received induction, training, supervision and appraisal relevant to their role and responsibilities.

The service followed the requirements of the Mental Capacity Act 2005 (MCA) Code of practice and Deprivation of Liberty Safeguards (DoLS). This helped to protect the rights of people who lacked capacity to make important decisions themselves.

People were supported to receive adequate nutrition and hydration and meal times were a positive experience for people, with choices available.

Staff had developed positive relationships with people, providing not only the physical care people needed, but also considering the quality of life of each individual person.

Relatives told us staff were caring towards their relative and treated them with respect.

Assessments, care plans and risk assessments were in place and reviewed, which meant staff had information in order for them to respond to people’s needs. Health professionals were contacted in relation to people’s health care needs such as doctors and community health teams.

People were confident in reporting concerns to the registered manager and provider and felt they would be listened to.

There were systems in place to assess and monitor the quality of service provided, to identify improvements needed and ensure improvement to achieve compliance with regulations and people’s experience of the service.

Although people and their families told us they were treated with respect by the staff, we found that people were not always treated with respect as we found beds that had been made, ready for people to use that had dirty sheets on them.

People told us they received the care they needed and before they were provided with any care, treatment or support, staff asked if they agreed to it. One person said, “It’s ok here, you’ve got to accept it. District nurses come and do their job and then buzz off. I like to read my paper. The only problem I have is you get up, come down and plonk in a chair all day. I get up and walk about. The meals are good, I eat what they give me. I’ve never refused anything.” This was not always reflected in their personal records and records were not always kept safe and confidential.

People were not protected against the risks associated with medicines because appropriate arrangements were not in place to manage medicines safely.

The provider was in the process of refurbishing the premise, which would enhance people's wellbeing.

We found there were sufficient numbers of staff on duty to meet people’s needs and staff were now receiving training relevant to their role, providing them with the opportunity to develop and improve their skills. The majority of staff felt supported by the manager.

Quality checking systems were gradually being introduced to manage risks and assure the health, welfare and safety of people who received care.

Staff did not always take into account people’s views in the care and support offered to them. For example, being able to get up at the time they wished and being able to have a television in their own room.

People’s privacy had been compromised on the dementia unit because information about them had been displayed on walls in the unit.

Staff were moving a person using the service from one unit to another without valid consent, which did not follow the principles of the Mental Capacity Act 2005.

People had their needs assessed and a plan of care formulated from that assessment, so that staff knew what to do to meet people’s needs.

The service had not always acted in accordance with local safeguarding procedures when an allegation of abuse was made, but had taken action to safeguard people.

We found there were not always sufficient numbers of staff with the right qualifications and skills on duty to meet people’s needs. This was because in an afternoon staffing levels reduced, leaving people unsupervised. This included people who were identified as at risk of falls.

The provider did not have an effective system to assess and monitor the quality of service provision. We found the provider had not learnt from previous incidents that had occurred at the home to minimise the risk of the same incident occurring again.

Audits to identify, monitor and manage risks to people using the service and others to proactively improve the service had not taken place.

This inspection was to review improvements at the service after compliance actions were served on a visit on 12 April 2012. We also covered outcome area 5, ‘meeting people's nutritional needs’ as we had received a letter of concern that we identified related to possible concerns about the tea time meal.

The home is divided into three separate areas. These consist of ten beds allocated to rehabilitation. Twelve beds allocated to residential care and eleven beds allocated to people with a diagnosis of dementia. We carried out our inspection in the area supporting people with dementia. Because people with dementia are not always able to tell us about their experiences, we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people. We carried out the SOFI for one hour during the lunch and tea time meal.

We saw that the service had introduced a separate dining area in the dementia unit as identified in their action plan as a way to improve the meal time experience for people. They had also implemented a menu board that was suitable for people with dementia, both having a picture for the meal and written information about what the meal was. Staff needed further instruction on it's use, to make it an integral part of meal experience.

We saw that at meal times people were served their meal on crockery that research had determined promoted independence and good dietary intake. The provider, manager and staff told us this had improved the dietary intake for people.

We saw that staff gave people their medication during the lunch and tea time meal and a staff member was encouraging people with singing. This meant people were interrupted and distracted from the main focus of eating their meal.

We saw from the menu board there was an alternative at both the lunch and tea time meal. We saw staff supporting people to eat their meals, where they were unable to do this themselves. We saw that staff spent time with them encouraging them to eat and that people were not rushed when being helped with their meal. However, we saw one person at the tea time meal that needed prompting and assisting throughout their meal and the staff member stood throughout this assistance, which is not good practice.

We saw that the provider had increased staffing levels, which meant two staff were available on the dementia unit. This meant that people were not waiting to have their care needs met.

We spoke with a relative of someone who used the service. They told us that they felt their relative had their personal care and welfare needs met. Their descriptions of their relative matched with our observations and what staff had told us. The relatives told us staff kept them informed and involved them in decisions relating to their relatives care. They said, "We'd all sing their praises. It might not be as it ought to, in relation to regulations, but we're happy. Things are better at meal times. It's more organised. At times people have a tray, but that's just as you'd be at home. We've no concerns. Mum's well cared for."

This service has three different types of service provision, provided in three different areas.

Ten beds are allocated to a rehabilitation service.

There is an 11 bed specialist service for people with dementia care needs.

There are a further 12 beds allocated to provide residential care.

Throughout the home the atmosphere was relaxed and staff seemed comfortable when they were talking and interacting with people using the service.

We spent the majority of time on the inspection on the dementia unit.

Because people with dementia are not always able to tell us about their experiences, we sat in the lounge to observe their mood, how staff interacted with people and the environment.

Throughout the observation we saw the staff member working on that unit treat people with respect and courtesy. They were kind and supportive to people when engaging with them. The staff member smiled at people, which offered reassurance to them and spoke clearly at a steady pace to engage with people.

However, we saw some examples where staff had not offered people adequate respect and protection for their dignity. For example, we saw one person who had porridge on their clothing and another spillage on the front on their jumper. Several people looked as if they had not had their hair brushed or styled since rising that morning, as it was flat to their head and looked greasy. We raised this with the member of staff who said they hadn’t supported those to people to get up that morning. The provider may find this useful to not, so that they can monitor this as part of their quality assurance, so that people's respect and dignity is maintained.

The majority of people were in a positive mood, which was demonstrated by them interacting with the staff. One member of staff engaged all but two people in a game of card bingo and then a game of skittles. This maintains people’s welfare and promotes their wellbeing, by taking account of their social and daytime activity needs. This staff member also demonstrated good interactions with another person using the service by providing them with a book to look at pictures of the local area, which they were observed to enjoy. One person was asleep during the whole observation.

Whilst acknowledging the positive observations between staff and people using the service and the overall environment, where care had been taken to provide facilities to orientate people, there were still improvements that are needed to improve the care and welfare needs of people with dementia. For example, at lunch time in the dementia unit, the lounge was transformed into a dining room. This means the environment does not have sufficient space to care for all aspects of peoples’ needs. Neither does it respect people’s dignity and needs, as changing one environment to another can be disorientating to people with dementia. There was no other area for people to use other than the corridor area and their own bedroom. This could become problematic in managing people’s behaviour that challenges if there isn’t a different area for them to go to.

The meal time and snack arrangements for people with dementia needed improvement. This was because there was no menu information for people on the dementia unit about their meal, or any choices that may be available. Their lunch was brought to them pre-plated. The staff member asked people if they enjoyed their meal. One person said, “it wasn’t as nice as earlier in the week, as it wasn’t as hot”. The meals were not taken to the dementia unit in a bain-marie to keep them at the correct temperature, which means the food may not be delivered to people in a way that meets the requirements of the Food Safety Act 1990. One person was served their meal all liquidised together. This is not good practice as the food is not presented in an appetising way to encourage people to enjoy their food and help people to recognise the different items they are being served. For example, one person was discussing their meal with the staff member. The person didn’t think they’d had any meat, when in fact, they’d had chicken that had been liquidised in with the rest of their meal. One person was seen to be ‘ignored’ when they wanted a drink. This did not offer the person an adequate level of respect. We spoke with the staff member about this and they told us there was no facility for making drinks, they had to wait until drinks came. This did not meet people’s needs.

During our observations and discussions with staff we were of the opinion there were insufficient staff to meet people’s needs in a timely way. This was because staff on the intermediate care and dementia unit relied on buzzing for assistance of another staff member on the residential unit if they needed it. This meant people had to wait for assistance if they were busy. On the dementia unit this presents a health and safety risk, both to other people on the unit and staff, if people using the service display behaviour that challenges. On the afternoon shift this becomes more of a concern as the member of staff offering assistance would be leaving their own area unsupervised because only three members of staff are on duty.

We spent some time gathering people’s views about the service from those people who were able to describe their experiences to us. They described the choices they made on a daily basis, such as when they got up and went to bed and meals. The majority of people told us they felt staff treated them with consideration and respect.

Everyone we spoke with told us they felt safe at the home.

This inspection took place over two days on 1 and 3 December 2015. The inspection was unannounced. An unannounced inspection is where we visit the service without telling the registered person we are visiting.

Thornhill House is a residential care home registered to accommodate 35 older people. At the time of the inspection 32 people were living at the home. The home is operated as two units, one for people requiring rehabilitation, with the intention of returning home and one for people who have personal care needs, some of whom are living with dementia.

The service did not have 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 and associated Regulations about how the service is run. The person managing the home had done so for almost four months and had applied to become registered. Feedback from people, relatives, staff and other stakeholders were that the new manager was making a positive difference to the service.

Since 9 July 2013 Care Quality Commission inspectors have carried out four inspections and have found a history of breaches with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. At the inspection on 10 and 16 March 2015 four breaches of regulation were identified. These were associated with safe care and treatment, staffing, need for consent, good governance and complaints. At this inspection we checked that improvements had been made to meet those regulations.

When we spoke with people who used the service they all told us they felt safe. Relatives spoken with did not raise any concerns about mistreatment or inappropriate care provision of their family member. Staff had received safeguarding training and were confident the manager would act on any concerns.

We found staffing levels were sufficient to meet people’s needs, but recruitment of staff did not include all the relevant information and documents required to ensure staff were suitable.

Systems and processes were in place for the safe administration of medicines, but we saw areas where some improvements were needed.

We checked and found some systems in place for how the service managed risks to individuals and the service to ensure people and others were safe, but improvements were needed with the monitoring of hot water and surfaces, fire drills undertaken by staff and the monitoring of falls.

Staff received induction, training, supervision and appraisal relevant to their role and responsibilities.

The service followed the requirements of the Mental Capacity Act 2005 (MCA) Code of practice and Deprivation of Liberty Safeguards (DoLS). This helped to protect the rights of people who lacked capacity to make important decisions themselves.

People were supported to receive adequate nutrition and hydration and meal times were a positive experience for people, with choices available.

Staff had developed positive relationships with people, providing not only the physical care people needed, but also considering the quality of life of each individual person.

Relatives told us staff were caring towards their relative and treated them with respect.

Although assessments, care plans and risk assessments were in place and reviewed, we found records were not always complete. Health professionals were contacted in relation to people’s health care needs such as doctors and community health teams.

People were confident in reporting concerns to the manager and provider and felt they would be listened to.

There were systems in place to assess and monitor the quality of service provided, but these had not always identified improvements needed and ensured sufficient improvement to achieve compliance with regulations.

We found one breach of 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 the report.