We inspected Town Thorns on 01 and 06 November 2017. The inspection visit was unannounced on the first day, and announced on the second day.

Town Thorns is divided into four separate units over three floors and provides personal and nursing care for up to 66 people of all ages, including people living with dementia and physical disabilities. There were 57 people living at the home when we inspected the service.

A requirement of the service’s registration is that they 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 the associated Regulations about how the service is run. There was a registered manager in post at the time of our inspection visit. We refer to the registered manager as the manager in the body of this report.

We last inspected this service on 15 February 2017, when we found Safe was rated ‘Requires Improvement’. We found there was a breach in Regulation 13, as safeguarding concerns had not been consistently reported to us across the different units at the home. Senior staff had not always identified incidents as safeguarding concerns, and reported them to the correct authority for investigation. We also found there was a breach in Regulation 12, because individual risks to people’s health and well-being were not always managed and mitigated. At this inspection we found improvements had been made and have rated the service as ‘Good’ in Safe.

Since our inspection on 15 February 2017 we have reviewed and refined our assessment framework, which was published in October 2017. Under the new framework certain key areas have moved, such as support for people when behaviour challenges, which has moved from Effective to Safe. Therefore, for this inspection, we have inspected all key questions under the new framework, and also reviewed the previous key questions to make sure all areas were inspected to validate the ratings.

At our previous inspection we had identified that safeguarding concerns were not always appropriately referred to CQC and other agencies, and were not always fully investigated, to ensure people received safe care. At this inspection we found the home had made significant improvements to how safeguarding concerns, accidents and incidents were categorised, analysed and investigated. We found monitoring systems were in place to identify any patterns and trends arising from such concerns. In addition the manager had arranged refresher training for all staff on how to document such concerns, and how to refer concerns to the management team for investigation. The manager had notified CQC and the local authority of any concerns which required investigation.

At our previous inspection we found Individual risks to people's health were not always being managed appropriately to ensure people were protected. At this inspection we found risk management plans had been updated to ensure the environment and premises were managed safely, and risks to people were minimised. In addition, we found people had individual risk assessments completed and staff were instructed on how to minimise risk to people’s health and wellbeing.

Most people told us there were enough staff to meet their needs, and there were enough staff during our inspection visit to ensure people were cared for safely. However, two people, on the residential unit, told us they sometimes had to wait for assistance to go to bed, in the evening.

All necessary checks had been completed before new staff started work at the home to make sure, as far as was possible, they were safe to work with the people who lived there. People were supported by a staff team that knew them well, as the use of agency staff had been reduced since our previous inspection.

Staff received training and had their practice

We inspected Town Thorns on 15 February 2017. The inspection visit was unannounced.

Town Thorns is divided into four separate units over three floors and provides personal and nursing care for up to 66 people of all ages, including people living with dementia and disabilities. There were 57 people living at the home when we inspected the service.

A requirement of the service’s registration is that they 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 the associated Regulations about how the service is run. There was an experienced registered manager in post at the time of our inspection visit. We refer to the registered manager as ‘the manager’ in the body of this report.

Care and nursing staff received training in safeguarding adults and understood the correct procedure to follow if they had concerns. They were confident if they raised concerns with their manager, these would be investigated appropriately. However, we found that safeguarding incidents were not always recorded and referred to the local authority by managers, as some incidents were being addressed as behavioural concerns. The provider had not identified that safeguarding concerns were not consistently reported and investigated as such.

Individual risks to people's health were not always being managed appropriately to ensure people were protected. In addition not all incidents at the home were being investigated and recorded on an accident and incident log, to ensure risks to people were being managed, and any trends and patterns could be identified. The manager reviewed their procedures following our inspection visit to ensure accidents, incidents and safeguarding concerns were recorded and reported consistently in the future.

We received mixed feedback about whether there were enough staff throughout the home. On the residential unit we received feedback that staffing numbers were not always sufficient to ensure people were cared for safely. The manager was introducing quality assurance and monitoring measures to review the number of staff allocated to each unit at the home.

All necessary checks had been completed before new staff started work at the home to make sure, as far as was possible, they were safe to work with the people who lived there. People were supported by a staff team that knew them well. Staff received training and had their practice observed to ensure they had the necessary skills to support people. Staff treated people with respect and dignity, and supported people to maintain their privacy and independence.

People had been consulted about their wishes at the end of their life. Plans showed people’s wishes about who they wanted to be with them at this time and the medical interventions they agreed to.

People received their medicines as prescribed to maintain their health and wellbeing. People were supported to access healthcare from a range of professionals inside and outside the home and received support with their nutritional needs. This assisted them to maintain their health.

The provider, manager and staff understood their responsibilities under the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS) to ensure people were looked after in a way that did not inappropriately restrict their freedom. The manager had made applications to the local authority where people’s freedom was restricted, in accordance with DoLS and the MCA requirements. Decisions were made in people’s ‘best interests’ where they could not make decisions for themselves.

People were supported to take part in social activities and pursue their interests and hobbies. People made choices about who visited them at the home, which helped people maintain personal relationships with

We inspected Town Thorns Care Centre on 3 December 2014 as an unannounced inspection. At the last inspection on 22 May 2013 we found that there were no breaches in the legal requirements and regulations associated with the Health and Social Care Act 2008.

Town Thorns is divided into four separate units over three floors, providing accommodation and nursing support to up to 66 people of all ages. There were 54 people living at Town Thorns when we inspected the service.

A requirement of the service’s registration is that they 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. There was a registered manager in post at the time of our inspection.

We spent time in communal areas over the course of the day and saw interactions between people and staff were respectful, cheerful and kind.

People told us they liked the staff. It was clear staff had a good understanding of people’s communication abilities and adapted their approach accordingly.

People told us they felt safe. There were sufficient staff. The managers and staff were knowledgeable about how to meet the needs of people in their care, and how to protect them from abuse.

People’s care records and associated paperwork was not always up to date. We have made a recommendation about the management of record keeping.

Improvements were required to the medicine administration procedure, to ensure medicines remained effective, and were administered only when required. We have made a recommendation about the management of medicines.

Staff told us they received suitable induction and training to meet the needs of people at the home. Staff received regular supervision meetings and yearly appraisals. This meant people were being cared for by suitably supported and trained staff.

There were appropriate policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) to ensure that people who could not make decisions for themselves were protected.

We saw people had access to health services and were assisted to maintain their health and well being.

Everyone we spoke with told us staff were kind and caring. We found that people’s privacy and dignity was respected.

People and their relatives were involved in planning and agreeing their care. The care we observed matched the information on people’s care plans, which meant people were offered support that met their individual needs.

The manager had sent notifications to us appropriately about important events and incidents that occurred at the home. They were aware of their responsibilities in notifying regulatory bodies and authorities about important events at the home, and were acting accordingly.

Staff told us they were well supported by the wider organisation, and that support was available from the provider when required.

The provider completed a number of audits to monitor the service, and to drive forward improvements.

During our visit we spoke with nine people about their experience of living in the home and spent time on each of the four wings of the home. We were told, “I am happy here” and “I am well looked after.”

We spoke with five visitors who made positive comments about the care and support their relatives received. We were told, “I visit each day and have no concerns” and “The staff are caring.”

We looked at the care records for five people and found that their needs were assessed prior to admission so that plans of care and support reflected the way people liked and needed to be cared for. We found that care records were reviewed on a regular basis to make sure they accurately described the care people needed.

People told us they had opportunities to take part in activities which they enjoyed. One person commented, "There is something to do every day. There is never a dull moment."

We observed that staff responded promptly to people when they asked for support and treated people with respect whilst providing care.

We found the home to be clean with systems in place to prevent the risk of the spread of infection.

People living in the home and their visitors told us they had been provided with information about raising concerns and complaints. We were told, "The staff make every effort to resolve any concerns."

We found there was a system in place to recruit new staff so that people were not placed at risk of having unsuitable staff working in the home.

We visited Town Thorns Care Centre on 29 May 2012. The visit was unannounced so that no one living or working in the home knew we were coming.

The home is made up of four separate units, each of which has a designated staff team. We spent time in each of the four units and spoke with people and their visitors as well as members of staff on duty during our visit. We sampled six sets of care records across the four units and spoke with health care professionals that visit the home on a regular basis.

Some of the people that use the service at Town Thorns Care Centre have dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences people have we used our SOFI (Short Observational Framework for Inspection) 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 received positive comments about the staff team from the health care professionals we spoke with. We were told, “They communicate effectively, are quick to refer people whose health needs are of concern. They keep detailed records.”

We saw that people’s needs had been assessed before they moved in to the home. Care plans had been devised to describe how people liked and needed to be supported. Risks to people’s health and well being had been identified and measures had been put in place to protect people.

The care plans we looked at were being reviewed on a regular basis to ensure they accurately reflected any changes to people’s needs. A visitor told us, “I am kept fully informed of any changes by the staff.”

People that live in the home told us they felt safe and comfortable there and that the staff were kind and friendly. A visitor commented, “I visit two or three times a week and always get a guaranteed warm, pleasant welcome from the reception staff in the main building and the staff in the unit.”

The staff team on duty were polite and respectful when offering care and support to people. We observed that people sought out the company of members of staff and it was evident from people's body language and facial expression that they were comfortable with them.

We spoke with two visitors about the care provided to their family members and they told us that the care delivered to people was good. When they had a concern they told us they were able to talk to the manager and staff about this and were confident it would be looked into.

We saw that people had opportunities to make decisions about where they spent their time, whether to join in with planned activities and what to eat and drink at lunch time. Some people chose to eat in their bedrooms, which was respected by the staff team.

People told us there were lots of things to do and that they had busy and active lifestyles. One person commented, “There’s always something going on.”

The staff we spoke with told us they were happy working at the home and felt well supported by the management team. We were told that training opportunities were frequent and planned to ensure staff had sufficient knowledge to meet people’s needs.

We saw there were quality assurance systems in place which measured people’s satisfaction with the service provided in the home. People and their visitors told us they were aware of the procedure for making complaints and were confident any concerns raised would be taken seriously and acted upon. A visitor told us, “I have only had to raise minor issues and these were dealt with very promptly.”

The visitor also told us that they had attended a relatives' meeting and gave examples of where improvement had been made when issues were raised.