CQC report explained · a residential care home
What the CQC found at 14 Thornholme Close
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2022
Rated Inadequate and placed in special measures; inspectors found serious risks from unskilled staffing, poor oversight and care that was not consistently person-centred.
This was the first inspection of the newly registered home. Inspectors visited on 31 March 2022 and continued inspection activity until 19 April 2022. They spoke with relatives, staff and professionals, and reviewed care, risk, incident, recruitment and management records.
The home was rated Inadequate overall. Safe, Effective and Well-led were rated Inadequate. Caring and Responsive were rated Requires Improvement. Inspectors found too much reliance on agency staff, gaps in training, unsafe or unsuitable parts of the environment, poor incident reporting and weak management oversight.
People's communication needs were not always understood or supported. Inspectors also found that incidents were not always reported as safeguarding concerns, lessons were not consistently learned, and some records used language that did not show respect for autistic people or people with learning disabilities.
The home was placed in special measures. The provider was asked for an action plan, and CQC said it would work with the provider and local authority to monitor progress and take further action if needed.
Recruitment checks
The provider had completed the required pre-employment checks for new permanent staff.
“The provider's recruitment practices were safe. Necessary pre-employment checks had been completed for new permanent staff to ensure they were suitable for employment in the care sector.” from the report
Food and drink
The person was supported with a balanced diet that followed their dietary requirements.
“People were supported to maintain a balanced diet and the service was following the person's dietary requirements.” from the report
Family involvement
Relatives were involved in decisions about care, including personal routines and how support should be given.
“People's relatives were involved in decisions about the care provided.” from the report
Family contact and activities
The home supported family visits, school provision and access to a secure garden. A trampoline was reported to help reduce anxiety.
“The provider purchased a trampoline, and this worked well to reduce anxiety for the person at the service.” from the report
Unsafe staffing levels and skills
seriousThere were not enough skilled permanent staff, and the home relied heavily on agency staff. One agency worker had worked about 80 hours over six consecutive days, without the impact being risk assessed.
“The service did not have enough skilled employed staff to meet people's assessed needs and there was an overreliance on agency staff to deliver care.” from the report
Insufficient staff training
seriousMost agency staff had not been trained in the person's communication methods or in managing distress and aggression. The provider also lacked oversight of agency nurses' skills.
“The majority of agency staff working at the service had not received training for people's communication needs.” from the report
Unsuitable environment
seriousThe bungalow was too small for people's needs and did not provide enough space for someone to calm down when distressed. A mirrored wardrobe and a medicines cabinet also presented risks.
“The property was not suitable for the care and treatment provided. The layout of the bungalow was not big enough to accommodate people's needs.” from the report
Poor communication support
seriousStaff did not always use the communication methods set out in care plans. During one incident, staff did not use the person's communication method to explain that a bus was late, and the person became distressed.
“The person's preferred communication was limited Makaton and picture exchange communication system (PECS), however the service was not equipped to deliver this support to the person.” from the report
Weak management oversight
seriousThe provider and manager did not identify or act on widespread problems in safety, staffing, incidents and safeguarding. This led to multiple breaches of regulation.
“The provider had not identified the widespread and significant shortfalls in the safety and quality of the service which had let to multiple breaches of regulation and placed people at risk of harm.” from the report
- 01How many permanent staff now work at the home, and how much agency cover is still being used?
- 02What training and competency checks do staff have for autism, Makaton, PECS, positive behaviour support and managing distress?
- 03How are safeguarding incidents, accidents and near misses now reported, reviewed and used to change care plans?
- 04What changes have been made to the bungalow's layout and identified environmental risks?
- 05How will staff support the person's preferred communication method in everyday situations and during unexpected events?
This was the first comprehensive inspection of the newly registered home and covered all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 6 July 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 14 Thornholme Close
Each visit the CQC has published, newest first, back to the day the home was registered.
- July 2022Inadequatecurrent ratingSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2019
Registered with the Care Quality Commission on 22 July 2019.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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At least 100 live-in carers within about an hour of Manchester
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 89 can care for a couple. 10 years' experience on average.
“Primrose is a very kind and compassionate healthcare professional”
“She is an exemplary carer, she is knowledgable empathetic and very respectful in the home.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.