Thomas Knight Care Home

We carried out our on-site assessment on 13 August 2024, off-site assessment activity started on 13 August 2024 and ended on 11 September 2024. We looked at evidence categories in Safe and Well-Led. There were areas of improvement for the service to focus on, most notably governance and oversight. The provider and registered manager had not always ensured there were effective governance in place to ensure safe and effective care at all times. We therefore found the service was therefore in breach of regulation 17 (good governance). Documented analysis of incidents had only started in the previous month, at the request of other stakeholders, and there was a lack of formal auditing documentation to identify issues and demonstrate improvements. Concerns regarding the environment, staff being bare below elbow, safeguarding responses, and medicines record keeping, could reasonably have been addressed prior to our visit, with effective governance processes in place. Feedback was mixed about the responsiveness of leadership and the availability of staff. The provider was open to feedback and they shared their policies and staffing arrangements promptly. There were positives, such as people’s descriptions of staff and how they engaged with people and their relatives. People felt safe and secure, and had access to a range of primary and secondary healthcare services when they needed. Improvements had been made to medicines record keeping, following support from other stakeholders. Safeguarding training, policies and procedures and policies were up to date. People and their relatives were involved in care planning and review. The culture was focused on people receiving safe care, but needed to be open to other ways of working, and explore best practice to continue improving. They had yet to demonstrate improvements were sustainable.