Trafford Waters Care Home Also known as Tanglewood Shared Services Limited

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. This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to staffing and safe care and treatment.

This service scored 56 (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 not always had a proactive approach to safety.

There had been a high number of falls in the home around January 2026. Relatives expressed concerns care plans had not been implemented correctly and claimed this had led to incidents that could have been prevented. Relatives told us, “They didn’t have things in place as we were told. They knew about [relatives] falls but weren’t prepared for this and…[relative] fell a couple of times” and “They are too reactive, they respond when we flag things, but why are they not proactively putting things in place to keep [relative] safe?”

The provider responded to the spike in incidents in January 2026 and had implemented effective measures to significantly reduce the number of incidents. This included reviews of people’s care and an analysis of the time and location of falls in the home.

Staff were trained and encouraged to report incidents, and any learning was shared during handovers and through additional training if required. Safety incidents were appropriately investigated and reported and were seen as an opportunity to put things right, learn and improve.

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.

To support safe and familiar transitions, people were offered visits, online video tours and the option of a large print brochure about the home. During the admission process, people were also offered the opportunity to attend taster days. This enabled them to spend time in the service, helping them to decide whether it was the right environment for them.

Processes were also in place to ensure people received continuity of care, for example, when being transferred to hospital.

There had been a relatively high number of concerns reported to the local authority safeguarding team.

We received a mixed response from people and their families. Some responses stated staff were kind and caring and people felt their relatives were safe with them. Quite a few relatives also expressed concerns about the impact of staffing levels on the quality of care and on people’s safety. They told us, “No, I haven’t any safety concerns with staff, [relative] isn’t getting abused, but she isn’t getting cared for properly” and “To be fair I have mentioned that some residents are unsafe and likely to fall and I have been in the lounge and have ended up helping other residents and I have raised that.”

Information about people who had suffered harm or were at risk of harm were appropriately shared with other agencies in a timely way. The registered manager had been working closely with the local authority safeguarding team and met with them weekly to discuss progress with individual cases.

Staff were supported through induction and training to understand their safeguarding responsibilities. We spoke with staff about safeguarding and observed their practice. Staff demonstrated a clear understanding of their responsibilities and how to recognise and report concerns.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In[care homes/hospitals], thiscan be donethrough a procedurecalled the Deprivation of Liberty Safeguards (DoLS),whichispart of the Mental Capacity Act 2005(MCA).We checked whether the service was working within the principles of the MCAand how they managed DoLS within the service.

We found that staff received training in the Mental Capacity Act and in dignity and respect, which supported them to uphold people’s rights. The staff we spoke with did not have a good understanding of the Mental Capacity Act. Additional training was being arranged to address this. Systems were in place to monitor applications to deprive people of their liberty, to ensure these were lawful and remained in date.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We received mixed responses from people, relatives and staff. It was not always clear people, and their families had been fully involved in managing risks appropriately. Families told us care plans were not always followed and some said they had to chase up care reviews, and this had impacted negatively on people’s care.

People were not consistently supported when expressing their needs, emotions or distress. During the assessment, we identified one person’s emotional needs care plan did not fully reflect their needs and it was not the least restrictive approach to their care. We requested this was reviewed and updated to ensure they received more appropriate, less intrusive support.

The home provided cases studies demonstrating where people had been supported to take positive risks enabling them to live as freely as possible within the home. Both examples provided good evidence of positive impactful interventions.

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 maintenance checks of the premises were completed to ensure safety requirements were met. Safety certificates were up to date, and any recommended actions had been addressed. This included electrical safety, fire safety, legionella management, and passenger lifts.

We requested further assurance about fire safety and the staffing levels required to help ensure the evacuation procedure is effective in the event of a fire at nighttime. We shared this information with the local authority and Greater Manchester Fire Service so they could assess if further support was required or not.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

The provider had processes in place to review rotas and staffing levels required to meet people’s needs. The registered manager was confident the home was overstaffed at the time of the assessment. However, this did not always match the experience of the people living there, people’s relatives, feedback from staff and observations from CQC and the local authority.

A high proportion of the relatives we spoke with expressed concerns about either staffing levels or the experience of the staff. They told us, “We do not feel staff have the experience or the skills. The turnover is incredible. Staff are constantly leaving” and “They are massively understaffed, they claim that they have the correct ratio of staff, but there isn’t enough staff and things are happening. There were no staff in the lounge, and my [relative] was in a heated argument with another resident, but no staff were there to diffuse the situation.”

A high proportion of staff we spoke with expressed concerns about staffing levels. They told us, “Downstairs was not good. They need 3 carers not 2 carers. There are more doubles downstairs. It was very demanding downstairs. The buzzer is going off, and you have to observe the lounge as well” and “Staffing has improved but still not right. Downstairs in particular is not right. It is full. They need 5 downstairs…There is 4 today and yesterday… Things are being done but it is a struggle. I have thought about leaving as it is exhausting. It needs 5 upstairs and down. Some staff did report an improvement since the more recent changes. They told us, “The last two weeks has improved. It was horrible before. I had considered leaving as it was stressful not being able to do your job. Quite a lot of staff have left.”

Training and support for staff had been identified by the provider as an area for improvement prior to the assessment. Actions were taken to ensure improvements were made to both medication and falls training, for example. However, further improvement was required to provide support to staff during their induction. Each staff member received a 3-day induction followed by 3 shadow shifts. There was a lack of support for new starters during this period to check on their progress and suitability to work unsupervised. Staff told us, “The first week it felt like I was in the deep end as I was not shadowing. I was expected to work…after 3 weeks I have not had a 1-1 yet to ask how things are going” and “It has been tough, short staffed and no structure, I was dropped in at the deep end. When I was shadowing, I felt like I was on shift, I am not sure I did any shadowing.”

This meant we could not be assured staff were receiving appropriate supervision and support to develop and progress in their roles.

Families and staff reported a high turnover of staff and told us sickness rates were also impacting on the quality of care. Agency staff were used to cover gaps in staffing rotas. However, they were not always effectively inducted into the service. For example, they had not consistently completed daily records as required, which meant important information about people’s care was not always documented.

Staff were recruited safely and had the appropriate pre-employment checks in place before employment commenced.

The provider did not always assess or manage the risk of infection effectively. They did not always detect and control the risk of it spreading. They did work well with appropriate agencies as required.

Staff reported issues with access to PPE (personal protective equipment), and this was resolved during the assessment. The registered manager said the home had enough stock, but the distribution needed to improve, to ensure staff had the access they required.

We observed poor hand hygiene prior to meals. Staff did not consistently wash their hands or support people to do so. This issue was identified in audits carried out in the home in January, February and March 2026. It was not clear what action had been taken to address this issue. We requested a response from the registered manager but did not receive a response.

The home had been inspected by the local authority infection control team in February 2025. The inspection scored 75% and an action plan was implemented to address the shortfalls. This was completed ahead of schedule. The council infection control team also provided face to face training in April 2026.

Two outbreaks occurred in the home prior to the assessment. Both were reported appropriately and dealt with effectively. Regular cleaning schedules were in place, and the home was visibly clean, fresh and odour‑free. Staff received training and the staff we spoke with understood their responsibilities.

Medicines were stored securely and managed by staff who had completed training and had their competency assessed. Staff recorded the temperature of areas used to store medicines and where records were available, they had been stored correctly however for one area staff were unable to provide records.

Records did not always reflect that medicines were administered as prescribed. We saw evidence of a person getting the wrong dose of their medicine on multiple occasions. A healthcare professional who had visited the service to monitor the person’s blood results had provided written instructions on the dose of medicine required each day. However, this guidance was not consistently followed by staff.

In addition, the persons electronic medication administration record (eMAR) had not been updated following the healthcare professional’s visit. However, this was rectified by the service following our feedback. For two people we saw that medicines containing paracetamol that require a four-hour gap to be left between doses were recorded as being given early. Medicines were not always available in the service for staff to administer which meant we saw that some people had missed doses of their prescribed medicines.

Staff did not always follow the manufacturer’s instructions when administering medicines. For example, where medicines needed to be taken before food or other medicines, or on specific days, these instructions were not consistently followed.

For people who were prescribed topical medicines such as creams it was not always clear from their records who had applied the cream or who was responsible for recording the application.

People had their allergies recorded and staff had information available on how individuals liked to take their medicines. People were supported to look after their own medicines when this was appropriate and staff completed risk assessments to ensure this was done safely.

The service completed weekly audits related to medicines. Audits had not always identified the concerns found during the assessment, which meant issues were not consistently recognised or addressed in a timely way.

When medicines errors had been identified there was evidence that the service investigated and completed lessons learned, however we found similar errors had re-occurred, so it was not clear how robust this process was.