14 April 2023
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.
The inspection was completed by 2 inspectors.
Service and service type
Tyspane 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. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was not a registered manager in post. The previous manager had recently left the service and a new manager had started employment with plans to register with us.
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 all this information to plan our inspection. 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.
During the inspection
We spoke with 14 staff including the manager, peripatetic manager, deputy managing director, nurses, administrator, chef, kitchen assistant, 2 administrator assistants and care and domestic staff. We spoke with 8 people living at the service and we undertook a range of observations as some people were unable to communicate with us. We spoke with 3 relatives visiting the service on the day of inspection. We reviewed a range of records about people's care and how the service was managed. This included 4 care plans and risks assessments, staffing rotas and recruitment files, a range of medicines and training records and quality assurance audits and reviews. We also received feedback from 4 staff via email following the inspection.
14 April 2023
About the service
Tyspane is a residential care home providing personal and nursing care to 45 people aged 65 and over at the time of the inspection. The service can support up to 69 people. Tyspane is a modern, spacious building with bedrooms over two floors accessed via a passenger lift. There are communal lounges and dining rooms on both floors. All bedrooms are en-suite. There were country views overlooking the well maintained grounds.
People's experience of using this service and what we found
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 felt safe living at Tyspane. People received safe care and were protected from the risk of abuse. Staff were aware of their responsibilities for keeping people safe and received safeguarding training. Peoples’ comments included, “Relatives were happy and felt safe leaving their loved ones at Tyspane. They said, “
People were supported by enough suitably experienced and trained staff who were safely recruited. Staff worked with health and social care professionals to help people maintain their health and wellbeing.
Medicines were safely managed by trained staff.
Risks associated with people's care had been regularly reviewed and were well managed.
Visitors were welcomed into the service and their views were sought, considered and respected. There was a welcoming, staffed reception area with information and beverages.
There were robust systems and processes in place to monitor the quality of the service. When required actions were taken, and the necessary improvement made. The registered manager was supported by the provider to identify concerns and learn lessons when things went wrong.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was Requires Improvement (published 25 January 2022). At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements in relation to premises and equipment and good governance. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.
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.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Tyspane on our website at www.cqc.org.uk.
We will continue to monitor information we receive about the service, which will help inform when we next inspect.