Tilsley House Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. The provider was previously in breach of the legal regulation relating to safe care and treatment. Improvements were found at this assessment and the provider was no longer in breach of this regulation. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. However, improvements were needed to ensure lessons could be fully learnt to continually identify and embed good practice. Accidents and incidents were reported and recorded. Staff were clear on their responsibilities to document accidents and incidents and monitor people afterwards. However, the quality of information in accident and incident reports needed to improve to ensure specific details of what happened were recorded. This was needed to enable a thorough review of the events and ensure all appropriate actions to mitigate future risks were taken. Actions documented were not always demonstrating all aspects had been reviewed as needed. For example, when someone had a fall, the environment had not been reassessed. The registered manager had already identified this and was working with the staff team on making improvements.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service conducted a pre-assessment to ensure the service could meet people’s needs. This included how the service could meet people religious and cultural needs. Referrals were made when additional support was identified. People were involved and supported in their care pathway. For example, 1 person had chosen to move to another home to be nearer to family.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. Staff received safeguarding training and knew how to identify and report alleged abuse. Safeguarding concerns were monitored for progression and information shared with the staff team. Managers reported safeguarding concerns as required to the local authority and Care Quality Commission (CQC). Management audits reviewed safeguarding concerns and outcomes. The registered manager acknowledged where a clearer summary of any lessons learnt would be useful in showing what the service had done in response to outcomes found. Deprivation of Liberty Safeguards (DoLS) were applied for as appropriate. Staff monitored authorisations for conditions and expiry.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments had been improved to detail how to manage and support people in areas such as their mobility, health conditions and personal care. A relative said, “Personal care is well attended.” Guidance for staff described how to support people safely whilst maintaining their independence and involvement in their care. A person said, “I feel safe and looked after. They understand my needs.” Regular spot checks were conducted to ensure staff were delivering care safely and in a person centred way. Staff told us they valued constructive feedback and being supported to reflect on care practices. People told us, staff responded to their needs promptly. A person said, “There is always someone at the end of the call bell. If I press the call bell someone will be here within minutes.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular servicing and checks on equipment and the environment were conducted. A plan identified areas of the service for refurbishment. Improvements were being considered in line with peoples support needs and infection control risks. A relative said, “They have made [Name of person’s] room homely. Painted the front door and little touches recognising their past.” The provider’s business continuity plan detailed how unforeseen events would be managed. An on-call system supported staff out of office hours or in an emergency. A fire risk assessment was up to date and recommendations had been actioned. Staff conducted regular checks of fire safety and equipment, including fire drills. Personal evacuations plans detailed how people would be individually supported in an emergency. A garden area was accessible to people. A person said, “I can go out into the garden on my own.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Improvements had been made to make sure recruitment procedures were safe and the recommendation made at the last inspection was met. This included obtaining Disclosure and Barring Service (DBS) check, references from previous employment and a full education and employment history. Staff files were checked to ensure all steps of the recruitment process were completed.

An induction programme was carried out with new staff to orientate them to the home, people living there and systems in use. Staff received regular supervision with a line manager to review their performance, development and assist their well-being. Staff told us they were well supported. A staff member said, “Anytime I can speak to a manager. I get formal supervision as well.” A training overview monitored staff compliance with mandatory and other training. Managers conducted competency assessments in areas such as moving and handling and medicines to confirm training was embedded in practice.

Service leaders used a staffing dependency tool to monitor staffing levels against people’s assessed support needs. A person said, “There are enough carers.” We received positive feedback from people, relatives and health and social professionals about staff at the service. A person said, “Staff are absolutely lovely.” Relatives told us, “Carers are consistent. Staff are so thoughtful,” and “Staff are exceptional.” Staff absence and performance were well managed to provide consistent quality care.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The home was clean and tidy. Schedules documented which areas of the service were cleaned. Hand sanitiser was available and waste suitably disposed of. Staff had access to personal protective equipment (PPE) and this was observed being used appropriately. A person told us, “Staff know what they are doing. They wear gloves and aprons if they do any personal care.” The laundry area was well managed with clear systems to mitigate infection risks. A person said, “The home is clean and the laundry is well done.”

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People received their medicines as prescribed, including topical creams. Staff documented people’s preference of how they wished to take their medicines. A person said, “I get my medication on time, I know what I am taking and why.” Staff stored medicines safely, including where medicines required additional security measures. Temperatures of medicines storage areas were monitored to make sure medicines were stored as directed. Protocols for medicines given as required, directed how these were to be administered. Where medicines were administered covertly, this is where they are given in a disguised form, staff completed mental capacity assessments and best interest decisions with external health professionals. These were reviewed regularly. Senior staff had effective systems to clearly communicate information about changes to people’s medicines. A relative told us where staff had supported a person in reducing their medicines. A health professional said, “[A senior staff member] is very competent and helpful. Our medical plans are enacted diligently.”