CQC report explained · a nursing home
What the CQC found at Thistle Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe, and staff understood safeguarding. Some medicine storage and safety-check issues were found, but the manager took action to address them.
- Effective?
- Good
- People's needs and choices were assessed, and staff supported healthcare, healthy eating and recovery. The home provided training, supervision and development for staff.
- Caring?
- Good
- Staff were observed treating people with kindness, respect and dignity. People were involved in decisions about their care and were supported to develop independence.
- Responsive?
- Good
- Care was personalised and reviewed regularly. The home offered activities, family contact and community opportunities, but some complaints records did not clearly show how concerns were investigated and resolved.
- Well-led?
- Good
- The home had a welcoming and inclusive atmosphere, with management systems for monitoring quality and making improvements. People and staff were consulted about the service.
What inspectors found, July 2019
Thistle Manor was rated Good overall; inspectors found kind, personalised care, with some records and medicines processes needing improvement.
This was an unannounced inspection on 29 and 30 May 2019. Inspectors spoke with 10 people and 14 staff, and reviewed care plans, recruitment files, complaints, maintenance checks and quality monitoring records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People told inspectors they felt safe, and staff were kind, respectful and supportive. The home offered personalised care, activities, healthcare support and opportunities to build independence.
Inspectors found some issues with medicine disposal storage, recruitment records, safety checks and complaints records. The manager took action during or after the inspection, and the report says these matters were being improved.
Kind and respectful staff
Inspectors saw staff supporting people in a kind, friendly and respectful way. Staff knew people's needs, preferences and routines.
“We observed respectful and sensitive interactions between people using the service and staff.” from the report
Personalised recovery support
Care was tailored to people's needs and choices. The recovery-focused approach helped people build skills, confidence and independence.
“The provider's focus on rehabilitation and recovery, offered people opportunities for skill development, confidence building and positive wellbeing.” from the report
Good involvement and choice
People were involved in care planning, reviews, resident meetings and some staff recruitment. They were supported to make daily choices and manage parts of their lives.
“We observed staff offering choices, enabling people to make their own decisions and responding their preferences.” from the report
Activities and community links
People could take part in a wide range of activities and maintain contact with families and the community.
“People told us about the range of community and in-house activities available to them.” from the report
Positive atmosphere
Inspectors described the home as welcoming, friendly, relaxed and inclusive. Management systems supported the day-to-day running of the service.
“Thistle Manor had a welcoming, friendly, relaxed and inclusive atmosphere.” from the report
Medicine processes
needs fixingSome improvements were needed in the storage of medicines awaiting disposal and in person-centred medicine support. The manager took immediate action and planned further audits.
“There were some matters requiring attention including, unsuitable storage of medicines for disposal and promoting person-centred approaches.” from the report
Recruitment records
needs fixingThe provider carried out recruitment checks, but records did not always clearly show that every check had been completed.
“However, recording systems were not always clear in showing all checks were achieved.” from the report
Safety checks
needs fixingInspectors found issues involving window restrictor checks and hot water risks. These were fixed during the inspection.
“We noted some matters in need of attention, including checks on window restrictors and risks around hot water.” from the report
Complaints records
needs fixingComplaints were acted on, but some records did not clearly show how concerns had been investigated, managed and resolved. The manager said recording systems would be improved.
“Some records did not show a clear audit trail of how the concerns were investigated, managed and resolved.” from the report
- 01What changes have been made to medicine disposal storage and medicine audits since the inspection?
- 02How do you now make sure recruitment records clearly show that all required checks have been completed?
- 03How are window restrictors and hot water safety checked and recorded now?
- 04How are complaints recorded so that the investigation, action and outcome can be followed clearly?
- 05How will my relative be involved in setting recovery goals, reviewing their care plan and choosing activities?
This was an unannounced planned inspection of the care home, covering all five CQC questions and both the premises and the care provided. This explanation was written from the published report of 11 July 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.
What inspectors found, November 2016
Thistle Manor rated Good; inspectors found safe, kind and personalised care, with a minor issue about reviewing survey comments.
Inspectors visited on 8 and 9 November 2016. The first day was unannounced. They spoke with eight people living in the home, the manager and staff, and checked care plans, medicines records, recruitment files, rotas, complaints and audits.
The home supported up to 33 people with mental ill health, and 31 people were living there during the inspection. Inspectors found enough skilled staff, safe medicines systems, suitable staff checks and regular risk assessments.
People were treated with kindness, dignity and respect. They were involved in their care planning and supported with activities, health appointments, daily living skills and independence. The home received a Good rating in all five areas: Safe, Effective, Caring, Responsive and Well-led.
The inspection found that quality checks were in place and usually led to action. One improvement was identified: written comments from the latest satisfaction survey had not yet been brought together to address suggestions.
People felt safe
People told inspectors they felt safe, and staff understood how to recognise and report possible abuse.
“People told us they felt safe with the service provided and the staff who supported them.” from the report
Kind and respectful staff
Staff treated people as individuals, respected privacy and involved them in decisions about their care.
“We saw people were treated with respect and dignity.” from the report
Personalised support
Care plans were based on individual needs and reviewed regularly. People were supported to build independence through activities, cooking, work and other daily skills.
“People were involved in developing and reviewing their care plans and their views were listened to and respected.” from the report
Activities and recovery
People had a range of activities inside and outside the home, linked to their interests and abilities.
“People had completed activity planners based on their interests and abilities in order to give structure to their week.” from the report
Safe medicines
Medicines records were accurate and up to date. Staff also supported some people to work towards managing their own medicines.
“The records seen were accurate and up to date.” from the report
Survey comments not fully reviewed
minorThe home had analysed survey results, but inspectors found that people's written comments had not been collated to identify and address suggestions for improvement. The manager said this would be done after future surveys.
“However, we noted people's written comments had not been collated in order to address any suggestions for improvement.” from the report
- 01How do you now collect and act on people's written comments from satisfaction surveys?
- 02How would you assess and update my relative's care plan and risks after they move in?
- 03What activities and recovery goals would be available for my relative's interests and abilities?
- 04How would you support my relative to take part in decisions about care, medicines and daily life?
- 05How do you make sure staffing levels remain suitable when people's needs change or staff are absent?
This was a planned inspection of the overall service, with the first day unannounced, and it assessed all five CQC questions. This explanation was written from the published report of 30 November 2016 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 Thistle Manor
2 rated inspections over 3 years: the service has held its Good rating throughout.
- July 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 January 2011.
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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