Archived: Tunnicliffe House

Updated 21 June 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Tunnicliffe House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Tunnicliffe House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used information gathered as part of monitoring activity that took place on 31 March 2022 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.

During the inspection

We spoke with five people who used the service and eight relatives about their experiences of the care provided. We spoke to six members of staff including the registered manager, deputy manager, senior support worker, support worker, housekeeper and one of the owners of the service. We looked at three people’s care records and multiple medicines records. We looked at two staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 21 June 2022

About the service

Tunnicliffe House is a residential care home that provides accommodation and personal care for up to 16 people. Tunnicliffe House is a small domestic style building in a quiet cul-de-sac that offers accommodation over two storeys. At the time of our inspection there were 10 people using the service.

People’s experience of using this service and what we found

Some lessons had been learnt since the last inspection and improvements had been made to health and safety systems. All required environmental and smoking risk assessments were now in place.

Risks to people were not always managed effectively to protect them from potential harm. Additional risk assessments needed to be in place to mitigate risks around skin integrity and continence care for one person and another person who required blended foods. The provider had learnt lessons following incidents and accidents but had not recorded them.

People told us they received support from a consistent team of staff that knew them well. Staff were safely recruited and received training. There were enough staff to ensure people’s needs were met.

Medicines were managed safely by trained and competent staff. Infection controls procedures were in place and followed by staff.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People told us they felt involved, listened to and consulted. They said they attended regular residents’ meetings held at the service. People spoke positively about the provider and management team and said they were visible and approachable at the service.

The service worked in partnership with other agencies to support people’s physical and mental health needs.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 22 July 2019) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found that although some improvements had been made the provider remained in breach of regulations. This service has been rated requires improvement for the last two consecutive inspections.

At the last inspection a recommendation was put in place for the provider to review best practice guidance in relation to the principles of ‘Registering the Right Support.’ At this inspection we found the provider had done this however; all the people they continued to support had mental health needs and no new admissions had occurred since the last inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Tunnicliffe House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) at this inspection. The provider had not ensured all risks relating to people were considered and had not always taken prompt action following incidents that had occurred at the service. Systems were not always effective at identifying risks to people and taking prompt action to address them. Lessons learned were not consistently recorded.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.