Tilsley House Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. The provider was previously in breach of the legal regulation relating to good governance. 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 the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The aims and objectives of the service were described in the provider’s statement of purpose. Staff reflected these aims in their working practice, which we observed. People said, “It is a joyful place,” and “General welcoming atmosphere.” Managers had worked on improving the culture of the service since our last inspection. A staff member said, “The home has really improved.” Staff worked positively together and this meant people received quality care and support which met their needs. A staff member said, “It is a really nice place to work, like a family. Everyone is happy. We pull together as a team.” Staff were recognised through a reward scheme for going above and beyond. A relative said, “Staff are very thoughtful.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The service had a clear staff structure, with designated roles and responsibilities. Leaders demonstrated the knowledge and skills to manage the service effectively. A staff member said, “The managers work well together.” Leaders were approachable and supportive of staff and knew people well. A person said, “The registered manager is very approachable, they come round every morning and they know all our names. The deputy manager is lovely. I would go to them if I had any problems.” Leaders completed training relevant to their roles to develop their skill set. A relative said, “[The registered manager] is good with the team, supportive and visible. [The deputy manager] is super friendly and a good asset to the team.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Systems enabled staff to speak up including, supervisions, staff meetings and staff surveys. Where areas had been highlighted for improvement, these had been actioned. Regular staff meetings were facilitated and were well attended. A staff member told us, “Anytime we can bring up anything we want."

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff had access to equality training to support their understanding of protected characteristics and awareness of bullying and harassment. Staff told us they were fairly treated and staff members ethnic and religious backgrounds were respected and celebrated. For example, a religious festival was celebrated at the home for staff and people living at the service to enjoy different foods and traditional clothing. A staff member said, “It is a really diverse staff team. It runs so smoothly.” Staff were supported with their learning needs to ensure all staff could access training and progress with their professional development. The provider had an equality and diversity policy. We highlighted where data collected in relation to equality and diversity could be utilised better to demonstrate how this policy was put into practice. For example, data collected in the recruitment process.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Improvements had been made since our last inspection to governance systems to ensure they were effective. A range of management audits were conducted in areas such as medicines, care plans, recruitment and training. Regular audits completed were thorough and well organised. They ensured areas of the service were monitored, and actions required linked to the service’s action and improvement plan. This plan was regularly monitored for progress and completion of actions. This meant the service continually developed and improved. An external professional was currently undertaking provider levels audits of the service. Notifications of important events were submitted as required to CQC. Staff told us of the improvements in the service under the current management team. A staff member said, “Things have changed a lot, it is much improved. The quality of care, staffing and management,” and “Before, there was no continuity of management. It has changed for the better since the registered manager been in post. Staff and everyone are happy.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The service worked in partnership with other professionals and had positive working relationships with them. A health professional said, “The working relationship is the best, most efficient it has ever been.” The service ensured they communicated effectively with people’s families and within the staff team. A family member said, “Communication is excellent, they tell me everything.” A newsletter shared updates about the service with relevant people. Events were held which invited family, friends and stakeholders. For example, a summer fete was held which raised money for activities for people. A relative said, “The summer fete was great so many people came.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. However, some of the provider’s paperwork and external information was under a different company name. This included information within the statement of purpose and service user guide. This company is not registered with CQC. This could be misleading for the public and staff as documentation should be clear what the provider name is, particularly in the event of a complaint. The provider had a website, but it was not listed with CQC. We asked the provider to update us with this information. The CQC assessment rating was not displayed at the service as required. This was rectified during the inspection.

Feedback was sought from people, staff and relatives through questionnaires and meetings. Results were summarised and actions taken to address areas raised. A health professional said, “Residents and their families are actively involved in decisions about care, and feedback is welcomed, valued, and acted upon.” Systems within the service ensured changes were made when needed which resulted in positive care experiences for people. A person said, “They care for their people, the carers are exceptional. It’s a home from home.”