Thorn Springs

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.