Thorn Springs

Updated 9 May 2024

Date of Assessment: 29 May 2024 to 26 June 2024. We found a breach of regulations in relation to the governance and quality assurance measures in place at the service. Audits were sometimes not in place or were not effective in monitoring the quality of the service and putting measures in place to make improvements. Areas such as incident reporting, the reviewing of people’s care records, the reviewing of staff deployment, medicines management and ensuring staff training had been effective were not being audited effectively. This put people using the service at potential risk of harm. There were enough staff to support people safely, however staff deployment sometimes meant people went for long periods of time without meaningful conversations with staff members. Systems in place to monitor incidents and accidents and take actions in response to these were not always in place or robust. People’s care records were not always being reviewed effectively leading to possible safeguarding incidents being missed. Staff and the management team were not always updating people’s care plans in response to their changing support needs. Some improvements were needed to the way medicines were being managed. However, the management team acted immediately on most of our concerns and started to put measures in place to make and sustain improvements. Staff were completing health and safety checks of the environment and the service looked very homely. The service was clean, and staff followed good infection prevention and control practices. The management team operated an open-door policy and were visible at the service. The staff team felt mostly well supported by the management team. The management team took our feedback from this assessment seriously and sent us evidence of the changes they had or were going to make to start improving the service.

Updated 9 May 2024

Most people and relatives spoke positively about their experiences of living at the service and the support they had from the staff team. However, we received some mixed feedback from people’s relatives about some aspects of their family member’s support. Relatives gave us mixed feedback about how they were involved to feedback and be involved in their family members care. We also received some mixed feedback from people and relatives about staffing levels at the service, specifically around there not being enough opportunities for people to follow and be engaged in their preferred past times. Some people and relatives felt that as more people had started living at the service, people’s opportunities to access the community or take part in their preferred activities had been negatively impacted. We fed this back to the management team who assured us they would take action to make improvements in these areas. People and relatives told us the building was safe and secure and that they felt the environment at the service felt warm and welcoming. They felt the service was kept clean. People and relatives felt they/ their relative were safe living at the service. Most people and relatives told us staff were kind and caring when supporting them/ their family member. People and relatives were mostly positive about the management team and how the service was being led by them.