Tilsley House Care Home

Tilsley House Care Home is a residential care home and was providing care to 25 people aged 65 and over at the time of the inspection. The service can support up to 32 people. Accommodation is laid out over 3 floors, there are bedrooms on each floor, some of which have en-suite facilities. The ground floor offers a spacious lounge, conservatory and dining space and there is level access to the rear garden. The registered manager's office can be found in close proximity to the lounge.

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

Recruitment procedures were not always robust to ensure staff were safe to work in the caring profession.

Staff were not always given clear guidance about how to protect people from the risk of harm.

Medicines were administered as prescribed but were not always disposed of safely.

There were not sufficient facilities available for staff to easily maintain good hand hygiene.

Food and fluid records were not always accurate, and people were not always supported with the correct equipment to eat enough.

The provider did not have effective systems in place to monitor the quality of the service and make required improvements.

People and their relatives were satisfied with how the service was run and spoke highly of the registered manager. Staff morale had improved.

There were enough staff to keep people safe.

People were confident their concerns would be listened to and addressed.

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 mostly supported this practice.

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 good (published 21 July 2021).

Why we inspected

We received concerns in relation to the quality of the care. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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 good to requires improvement based on the findings of this inspection.

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

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and Recommendations

We have identified breaches in relation to person-centred care, safe care and treatment and good governance at this inspection.

We made recommendations in relation to recruitment and meeting nutrition and hydration needs.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Tilsley House Care Home is a residential care home and was providing personal and nursing care to 24 people aged 65 and over at the time of the inspection. The service can support up to 31 people. Accommodation is laid out over three floors, there are bedrooms on each floor, some of which have en-suite facilities. The ground floor offers a spacious lounge, conservatory and dining space and there is level access to the rear garden. The registered manager’s office can be found in close proximity to the lounge.

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

People told us they felt safe and staff worked to ensure care was provided safely. Risks were assessed, and measures were implemented to mitigate or remove them. People were protected from the risk of abuse and staff told us they would act if abuse was witnessed or suspected. Staff were recruited safely and there were enough staff to meet the needs of people. Lessons were learned when things went wrong. Medicines were managed and administered in line with requirements.

The provider and registered manager maintained oversight of the service. Quality checks and audits were undertaken to identify errors, concerns and omissions. There was a strong team identity and staff spoke positively about the registered manager. People received person-centred care, their views were sought, and the registered manager was accessible so stakeholders could speak with them as required. Staff worked with professionals to ensure people experienced good outcomes.

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 10 April 2019) and there was a breach of regulation 12 (Safe Care and Treatment)

Why we inspected

This was a planned inspection based on the previous rating.

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.

We carried out an unannounced comprehensive inspection of this service on 05 and 06 February 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment.

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.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service:

Governance systems were not always used effectively to identify gaps in records or areas that required further investigation.

People received personalised care that considered their individual needs. The registered manager was aware of the needs of people and knew them well.

Recruitment procedures were safe and staff members received training relevant to their roles.

The service worked effectively with healthcare professionals and were involved in pilot schemes and projects to help them improve the lives of people.

People and relatives spoke positively about the care provided by the service.

Safeguarding concerns were identified and appropriate actions were taken to protect people from potential abuse.

Rating at last inspection: The service was rated as ‘good’ at the last inspection. At this inspection we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to safe care and treatment, and good governance. The service was rated requires improvement.

Why we inspected: This was a planned inspection based on the previous rating.

Follow up: We will review the report on actions the provider intends to take following the inspection. We will continue to monitor the service through the information we receive. We will inspect in line with our inspection programme or sooner if required.

The service was previously inspected on 11 and 15 June 2015. At that time, it was found to be in breach of Regulation 11 because the provider had failed to ensure that care and treatment was only provided with the consent of the relevant person and did not take regard of the Mental Capacity Act 2005.

We asked the provider to draw up an action plan setting out how they would address the concerns. At this inspection, we found the provider had made the necessary improvements and the service was no longer in breach of this regulation.

Tilsley House Care Home is registered to provide accommodation for 31 older people who require personal care. On the day of inspection there were 28 people living at the service.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were safe as the service had systems in place for monitoring and managing risks to promote people's health and wellbeing.

There were suitable arrangements in place for medicines to be stored and administered safely.

There were sufficient numbers of staff, who were recruited safely, who had training to gain the relevant skills and knowledge to effectively meet people's needs.

People were encouraged to exercise choice and control in their daily lives and were involved in making decisions about the care and support they received.

People had access to food and drinks when they wanted them and they were able to make choices about this. A selection of food and drink was available that reflected peoples nutritional needs and took into account their preferences and any health requirements.

People’s rights being protected because the correct procedures were being followed where people lacked capacity to make decisions for themselves.

People were supported to maintain their health and had regular access to wide range of healthcare professionals.

People's privacy and dignity was respected.

People were treated with kindness and respect by staff who knew them well and who listened to them, respecting their views and preferences. Staff were caring and had good relationships with people and were attentive to their needs.

People were encouraged to follow their interests including religious practices and beliefs and were supported to keep in contact with their family and friends.

Staff enjoyed working at the service and were included in the running of the home.

The registered manager had systems in place to ensure the quality and safety of the service and to drive improvements and respond appropriately to complaints and feedback.

We spoke to nine people who all told us that the staff were very kind to them and always asked them what they wanted to do when seeking their consent.

We reviewed six care plans and noted they were all centred around each person's individual care needs. We saw detailed risk assessments that linked the care plan around needs such as pressure areas, nutrition and managing challenging behaviours. This ensured that the care and support that was given was safe.

People told us that they enjoyed the food at the home and really looked forward to their mealtimes. We observed that people were given choice about what they ate and were supervised to prevent them from becoming malnourished.

We observed that systems and processes were in place to reduce the risk and spread of infection. We observed that all areas were clean and tidy and were maintained to a good standard.

We observed quality assurance systems were in place in the form of audits and service user and relative and carer questionnaires. We noted that people were very happy at the home and relatives and carers felt well supported. Relatives and carers said "My relative has been given a new lease of life since being in the home". We noted that people at the home, relatives and carers were very satisfied with the service from the provider which was meeting their care and support needs.