CQC report explained · a residential care home
What the CQC found at Blackthorns
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2023
Blackthorns is rated Good; inspectors found safe, kind and well-managed care, with some records and improvement systems still being developed.
Inspectors visited without notice on 9 and 16 February 2023. They spoke with people living in the home, relatives, staff and other professionals. They observed care and checked care plans, risk assessments, medicines records, audits and policies.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff during their visits, safe medicines systems, effective safeguarding, kind staff and good access to healthcare. People were supported with food, activities, independence and visits from relatives.
Some improvements were still needed. Care plans were not always detailed or fully personal, some cleaning was needed on the first inspection day, and records about complaints, end of life wishes and service improvements needed strengthening. The previous overall rating was Requires Improvement in 2019, so the overall rating had improved to Good.
Kind and respectful care
Inspectors saw staff treating people warmly and respectfully. Staff also supported people to maintain their independence and dignity.
“Staff treated people with kindness, warmth and reassurance, and built positive and trusting relationships.” from the report
Safe medicines and risk management
Medicines were prescribed, given, recorded and stored safely. Staff understood safeguarding and managed risks such as falls and fire safety.
“People were supported by staff who followed systems and processes to prescribe, administer, record and store medicines safely.” from the report
Good access to healthcare
The home made referrals when needed and worked with healthcare professionals to support people's health.
“The service worked effectively with other agencies to ensure good and timely access to healthcare services and support.” from the report
Food and social life
People had appetising food, snacks and drinks, and could take part in activities and social events.
“There was a pleasant and sociable dining experience for people, and a choice of appetising food served in line with people's needs and preferences.” from the report
Cleaning needed attention
minorSome areas needed extra cleaning on the first inspection day. The home addressed this before the second visit and had arranged a deep clean.
“Some areas required additional cleaning on day 1 of our inspection, but this had been completed by day 2.” from the report
Improvement records needed strengthening
needs fixingThe home had audits and action plans, but its systems did not yet clearly show longer-term analysis, progress and outcomes. A local service development plan was recommended.
“Some systems and processes required embedding and additional development to show analysis of themes and trends, for example in complaints and safeguards.” from the report
End of life records needed more detail
needs fixingStaff knew how to support people at the end of their lives, but records did not always formally record people's wishes for holistic end of life care.
“Records required some further development to reflect staff practice and to formally document people's wishes about holistic end of life care.” from the report
- 01How are care plans for new residents completed, reviewed and made personal to their needs and preferences?
- 02How much agency staffing is currently being used, and how do you maintain continuity of care?
- 03What changes have been made to cleaning and maintenance since the inspection?
- 04How do you record and review complaints, missing belongings and any repeated themes?
- 05How are residents' end of life wishes recorded and kept up to date?
This was an unannounced inspection covering all five CQC questions, including infection prevention and control, with visits on 9 and 16 February 2023. This explanation was written from the published report of 10 March 2023 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.
What inspectors found, June 2019
Rated Requires Improvement; inspectors found kind care and safe medicines, but gaps in risk management, care records, staffing support and leadership.
Inspectors visited the home without notice on 8 and 10 May 2019. They spoke with people, relatives, staff and health professionals, and reviewed care records, medicines, training, recruitment and quality checks.
People were generally treated kindly and with respect. They said they felt safe, had good access to healthcare and were supported by staff who knew them. Medicines were managed safely, and complaints were investigated promptly.
However, risks were not always managed consistently. Care plans were sometimes out of date or contradictory, new staff had limited induction, and meal arrangements did not always provide enough choice or follow nutrition plans. End of life planning also needed improvement.
The overall rating changed from Good at the previous inspection in September 2017 to Requires Improvement. The home had an improvement plan, but the inspection found that existing checks had not prevented important shortfalls.
Kind and respectful care
People had good relationships with staff. Inspectors saw staff treating people with kindness, dignity and respect.
“Throughout the inspection we observed kind and caring interactions between staff and the people living in the service.” from the report
Medicines management
Medicines were ordered, given and monitored through clear systems. Records checked by inspectors matched the medicines held.
“There were clear systems in place for the ordering, administration and monitoring of people's medicines.” from the report
Access to healthcare
People had access to health professionals when needed. The home worked with services including district nurses, dieticians, GPs and occupational therapists.
“People told us that they had good access to health care when they needed it.” from the report
Complaints handled promptly
The home investigated complaints and used the findings to make improvements.
“The service had a complaints procedure and we saw evidence that where complaints had been received they had been taken seriously and investigated promptly.” from the report
Clean and maintained environment
The home was clean and had systems for infection control and repairs. Inspectors saw staff using protective equipment appropriately.
“The service was clean, and several visitors commented on the new flooring and how the service smelled and looked fresher.” from the report
Risks and incidents were not consistently managed
seriousSome risks were assessed but not followed through consistently. Incidents were not always recorded and reviewed, reducing the home's ability to learn from what went wrong.
“Lessons were not always learnt when things went wrong.” from the report
New staff needed better induction
needs fixingSeveral new staff had only shadowed experienced colleagues for two days. Inspectors found that at least one newer worker was working independently without enough knowledge of the people being supported.
“The induction of staff was not always thorough or personalised.” from the report
Meals and nutrition support were inconsistent
needs fixingThere was not always enough food to offer people a choice. The menu was not followed, and planned supplements for people at risk of weight loss were not available on the inspection days.
“However, we found that these plans were not being followed and there were no smoothies or cream shots available on the days of the inspection.” from the report
End of life wishes were not fully recorded
needs fixingRecords did not always show people's preferences for end of life care, including cultural or religious needs. One DNACPR decision needed follow-up because there was no evidence of consultation.
“There was not always evidence of consultation about people's preferences for end of life care.” from the report
Quality checks missed problems
needs fixingThe home had audits and an improvement plan, but its checks had not found all the shortfalls identified during the inspection.
“These had identified some but not all the issues that we found.” from the report
- 01What changes have been made to risk assessments and incident reporting since the inspection, including how lessons from incidents are checked?
- 02How do you decide when a new member of staff is ready to work independently, and how is their previous experience taken into account?
- 03How do you make sure people are offered a genuine choice of meals and that nutrition supplements are available and recorded when needed?
- 04How often are care plans checked and updated, and how do you confirm that staff are following them?
- 05Who is currently responsible for managing the home, and what evidence can you show of progress against the improvement plan?
This was an unannounced planned inspection covering all five CQC questions; it followed the previous Good rating and checked whether earlier shortfalls had been addressed. This explanation was written from the published report of 12 June 2019 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 Blackthorns
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2017Goodstayed GoodSafe: Good
- November 2016Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 December 2010.
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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