All inspections: Tilsley House Care Home

Date of Assessment: 2 to 17 October 2025. At our last assessment, we rated this service overall as requires improvement. At this assessment, we rated this service overall as good. Tilsley House Care Home is a residential service providing accommodation and personal care up to 32 adults some who are living with dementia. At the time of the assessment 26 people were living at the service. We carried out this assessment to review actions taken by the provider following our last assessment published in April 2023. We assessed 21 quality statements in safe, effective and well led. The provider was previously in breach of the legal regulations of person-centred care, safe care and treatment in relation to risks to people and medicines and good governance. Improvements were found at this assessment and the provider was no longer in breach of these regulations. Two recommendations had been made previously in relation to recruitment procedures and supporting people in line with guidance around food and fluid. The provider had made changes and met these recommendations.

Improvements had been made at the service to ensure people received safe and person-centred care. There was now a stable and skilled management team who implemented effective governance systems to monitor and assess the quality and safety of the service. Areas for improvement were identified and monitored through a service level action plan.

People received safe and effective care and were protected from the risk of avoidable harm. People received their medicines as prescribed. The home was clean and regular checks were undertaken on the environment and equipment. People could access the garden. Staff were recruited safely and were supported through an induction, supervision and training. Regular assessments of staff competency were undertaken to ensure person centre care was being delivered. People’s health needs were monitored and concerns were escalated promptly. The service had good working relationships with other health and social care professionals.

The management team were visible and approachable. They had worked to develop a culture, where staff worked well as a team and people enjoyed a positive atmosphere. Feedback was regularly gathered through surveys and meetings. However, the quality of information recorded in accident and incident reports needed improvement. The provider needed to address paperwork and documentation which referred to a previous company and not the current provider. This included the statement of purpose and service user guide.

About the service

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.

About the service

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.

About the service: Tilsley House Care Home is a residential care home that was providing personal care to 26 people aged 65 and over at the time of the inspection.

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 inspection took place on the11 August 2016 and was unannounced.

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.

This inspection took place on 11 and 15 June 2015 and was unannounced. It was carried out by two inspectors.

Tilsley House provides accommodation for persons for up to 31 older people who require nursing or personal care. The home is situated within walking distance of the beach at Weston- super-Mare.

People felt safe and told us they liked living at the home. People were complimentary about the staff and felt staff did their best to support them in a friendly and caring way. One person said, “Care that you wouldn’t get anywhere else.” People’s privacy and dignity was maintained during care tasks.

People told us they felt safe and free from the potential risk of abuse. Staff told us about how they kept people safe and were aware of their support needs. People received their medicines as prescribed and at the correct time.

Potential risks to people were identified and staff told us they knew the risks to people and the support needed to minimise these risks.

At times, there were not enough staff to meet the needs of people who lived at Tilsley House and staff told us they felt busy and did not have time to always deliver care to people when they needed it.

People received their medication when they required it and systems were in place which ensured people were administered their medication safely.

Staff supported people to make some choices about their care but some did not have a good working knowledge of the Mental Capacity Act 2005 or the Deprivation of Liberty Safeguards. Whilst no-one living at the service was currently subject to a DoLS, there had been applications sent to the Local Authority requesting authorisations as the home had a keypad on the front doors.

Some staff had not received appropriate training to meet people’s needs, for example dementia care or the Mental Capacity Act 2005.

Assessments of people’s capacity to consent and records of decisions had not been completed in their best interests. The manager could not show how people gave their consent to care and treatment or how they made decisions in the person’s best interests. Therefore, people had decisions made on their behalf without the relevant people being consulted. Staff had not received sufficient training to provide a safe and appropriate service that met people’s needs.

People told us the food was good and they had a choice of food and drinks. One person said, “Excellent food. I’ve not left a dinner since I started here.” We saw people’s nutritional needs were met. If there were concerns about their eating, drinking or weight this was discussed with the GP. Any support and advice from healthcare professionals was followed by staff in order to maintain people’s well-being.

We saw staff supported people patiently and with care and encouraged them to do things for themselves. Staff knew people’s likes, dislikes and needs. They provided care in a respectful way.

Although care plans contained information about people’s needs and wishes they were not comprehensive. They did not contain specific or sufficient detail to enable staff to provide personalised care and support in line with the person’s wishes.

People said they were happy with the activities offered. One person said, “We have special days and go out on trips”.

People were happy to talk to the manager and to raise any concerns that arose. They told us the manager and deputy were “Really nice and good”.

The systems in place to monitor the service and to obtain people’s feedback were not always robust and this placed people at risk of receiving a service that was not responsive or effective.

The registered manager had left the service shortly before the inspection. 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.

A new manager was in the process of registering with the Care Quality Commission. Many of the improvements needed to the service had been identified by the new manager and there was a plan in place to address them, but these had not been actioned at the time of our inspection.

We have made some recommendations to the provider so that they can make improvements to the service. We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report. of findings

There were 28 people living at the home at the time of our inspection.

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.

This visit was carried out to follow up concerns raised about the day to day care provided at Tilsley House and induction training for new staff. Evidence gathered from this inspection did not support or substantiate any of the concerns raised with The Care Quality Commission (CQC).

As part of this visit we also followed up compliance actions made at the last inspection which took place on 19 January 2012. We looked at outcomes which related to safety, availability and suitability of equipment, and supporting staff. During the inspection we also commented on outcome 20 Notification of other incidents.

We arrived at the home at eight o'clock in the morning as concerns had been raised that people were being got out of bed early without being given a choice. We found six people up sat in the lounge. We spoke to three people who agreed to speak about their experience. They all said they were happy to be up early. One person told us, 'I have always been an early riser, best part of the day.' Another person said 'I like to get up if I am awake, no point lying there thinking about things.' Later in the day we saw one person who told us, 'I have really enjoyed a good lie in this morning, just about to enjoy a late breakfast.'

During the inspection we spoke to seven people who lived in the home and two people who visited a relative who lived there. People told us that they were very happy at Tilsley House. One person told us, 'I have not been here long but they have been so helpful. They have already sorted out a few problems for me. The staff are so kind and caring. You hear some bad things about these places, but this is a really good place to live.' Another person said, 'They are all very kind and do their best but I would be happier in my own home.' One person told us that they liked the garden and they had plenty to do with books to read and going to the park.

During our visit we observed staff interactions with people. Every interaction was happy, friendly and respectful. People could take part in activities or chose to stay in their room. They all said they could do what they wanted throughout the day.

At lunch time we observed staff offered people a choice and provided alternatives if they were not happy with the options available. One person told us, 'I always enjoy lunch it is always worth waiting for and so relaxed.'

We carried out this inspection because concerns were raised with us about Tilsley House. One allegation was about equipment that was not well maintained and some poor practice when supporting people in bed. The second allegation was about the fitness of a member of staff and the fact that they were potentially unsafe to work as a result. And the third allegation was that the night staff had been told by the manager to assist some people out of bed between 5am and 7am against their wishes. We had contacted the local authority safeguarding department before our inspection to make them aware of the information. They had already been alerted about the alleged standard of the equipment and had followed up this allegation. They were not aware of the other allegations and an officer of the local authority decided to join us on our visit. The purpose of the visit was to check if people were safe and were assisted to get out of bed when they chose. It was also to find out if there had been any impact on the overall outcomes for people who used the service.

We did not speak to people on this occasion about their experiences as the majority of people were sleeping and we did not want to disturb them.

During our visit we found out that people were safe and were assisted to get out of bed when they wished. All bedrails had been checked for safety and action taken where necessary. There were no ongoing concerns in relation to bedrails.

Appropriate action has been taken by the provider in relation to the allegations about a member of staff not being fit to work. We were informed that this member of staff had been dismissed.

Overall we found the home to be compliant with only one of the three essential standards that we checked. Two compliance actions have been issued which the provider must meet to ensure that the service is compliant with the legislation.

We talked with people who live at Tilsley House Care Home. We were told that the home has something going on each day by way of activities. People we met said that they often joined in with activities, but only when they felt that they wanted to. We observed people at the home coming to the lounges and being helped to join the activity being arranged that afternoon.

We observed people being helped to do things for themselves and were told that although members of staff are attentive and supportive, that "they encourage me to do as much as I can for myself ". People said that they were able to get up in the morning and go to bed at night when it suited them.

We observed care and support being given to people at Tilsley House Care Home and saw it being delivered with sensitivity and kindness. We saw that members of staff knew people by name and that they spent time with them and gave them individual attention. We saw that there was a good relationship between members of staff and people living at Tilsley House Care Home.

We heard how people are encouraged to eat together, but if they prefer they can choose to eat in their rooms. We saw people eating in one of the two dining rooms situated on the ground floor. The people looked relaxed and comfortable and many were sitting with their friends. The food looked nicely presented and was ample in quantity and we observed that people could help themselves.

We talked with members of staff about their role in keeping people safe and protecting them from abuse. Members of staff were able to tell us what they would do if they suspected that a person was being abused. They were also able to tell us about whistle-blowing and all members of staff said that they felt confident that raising concerns internally would lead to action by the service.

We spoke to a number of people who were very positive about the care provided and their surroundings. As was the visiting health professional. We observed that it was comfortable and homely and the furnishings were up to standard.

A member of staff said 'I feel the staff team is working well'. 'This is progress'. 'The new provider is getting the right balance' 'He has settled well'. 'He is very approachable and communicates well'.

They also told us that 'the home was dated and dark'. 'He is making improvements, such as new carpets and re decorating and painting is on going'. They told us that 'room two is empty now and refurbishment is taking place'. 'He also plans to do refurbish the kitchen and we now have two separate dining rooms which is much better for people living here'.

Although our visit was prompted by concerns that had been reported to us, we found that the service was meeting all of the essential standards of quality and safety.

Tilsley House Care Home

All Inspections

During an assessment under our new approach

7 November 2022

During an inspection looking at part of the service

21 June 2021

During an inspection looking at part of the service

5 February 2019

During a routine inspection

11 August 2016

During a routine inspection

11 & 15 June 2015

During a routine inspection

23 January 2014

During a routine inspection

12 June 2012

During an inspection in response to concerns

19 January 2012

During an inspection in response to concerns

19 July 2011

During an inspection in response to concerns