Timperley 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.

At this assessment the rating has remained 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 regulation in relation to people’s safe care as medicines were not always managed safely.

This service scored 62 (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. Lessons were learnt to continually identify and embed good practice.

Learning from accidents and incidents remained a consistent priority for the provider. Established processes enabled the organisation to identify patterns such as trends in falls and take proactive steps to prevent recurrence. Staff were confident in accessing and using the electronic systems for reporting accidents and incidents. Leaders retained oversight through dedicated electronic dashboards, allowing them to review events, follow up promptly, and escalate concerns when necessary.

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.

Information was shared confidentially between health and social care partners. When people were admitted to hospital, whether planned or in an emergency, key details were passed on to ensure hospital teams were aware of their immediate needs. When people moved between services, relevant assessments were also shared, reducing the risk of any aspect of their care being overlooked.

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 were able to clearly explain how they identified and reported safeguarding concerns. They confirmed they received annual safeguarding training and felt confident in raising any issues with the registered or deputy manager. One staff member told us they had complete trust in the management team to take appropriate action.

All safeguarding concerns were referred to the local authority for further investigation. Learning from these incidents was shared with the wider staff team to support continuous improvement and reduce the likelihood of similar issues occurring again.

When people lacked capacity to make specific decisions about their care and support, the provider completed a capacity assessment. If a person was assessed as lacking capacity, a referral was made to authorise any deprivation of liberty considered necessary and in their best interests. Mental capacity care plans clearly outlined the decisions people could make independently and the support they needed where required. Staff recognised the importance of promoting people’s autonomy and told us that a diagnosis such as dementia does not mean a person loses control over their life, choices, or feelings.

The provider did not always work 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, however, further work was required to ensure the management of fluid thickeners to aid swallowing was safe.

Other risks to people were identified, assessed, and managed. Care records clearly outlined risks relating to falls, skin integrity, weight management, aggression, and the management of specific health conditions. Risk assessments were completed in partnership with the person, their representatives, and relevant professionals. They were person‑centred and supported positive risk‑taking where appropriate.

Staff were able to clearly describe the individual risks people presented. For example, one person was at risk of malnutrition and required additional encouragement to eat and drink. Staff explained that they offered smaller, more frequent snacks throughout the day to support the person’s nutritional intake.

People at risk of skin breakdown were regularly reviewed. Pressure‑relieving equipment, such as specialist mattresses, repositioning aids, and barrier creams, were used to help prevent pressure damage. Staff described how often people were repositioned and how this was recorded in the electronic care planning system. They also confirmed that any redness or early signs of skin deterioration were promptly reported to a nurse or senior care worker for further assessment.

Where people were at risk of falls, monitoring equipment such as chair and floor sensors was used. These alerted staff when a person was moving, enabling timely checks to ensure their safety and wellbeing.

People and their relatives told us staff were attentive and responsive to risk. One relative said, “[Name] receives palliative care and uses specialised equipment. When using hoists, staff know they need to be gentle. They understand [their] needs. The occupational health team have arranged a specialised shower chair. Staff check in at night, which is reassuring.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Oversight of premises safety was strong. Both internal and external checks were carried out by a competent person to ensure the building remained safe. Fire safety requirements were met, and staff understood the actions they needed to take if the fire alarm sounded. Individual evacuation plans clearly outlined how people should be supported to leave the building safely in an emergency.

A dedicated maintenance team was in place, enabling any environmental issues to be addressed promptly.

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.

Staff were recruited safely, with appropriate pre‑employment checks completed to ensure they were suitable to support vulnerable people. All staff received an induction to the service, their role, and the training required to carry out their duties. Additional learning opportunities were available for those wishing to progress, and nursing staff were supported to maintain and update their clinical skills. Staff received regular supervision, and managers assessed their competency to undertake specific tasks.

Most staff told us there were enough colleagues on duty to meet people’s needs. Two staff members commented that staffing could occasionally feel “tight”, although this was not reflected in our observations during the inspection. People and their relatives said they felt staffing levels were appropriate, and we did not observe anyone waiting for extended periods for care or support. Call bell response times showed staff attended promptly. One person told us, “The staff are lovely, and they always have time. It feels like an extended family.”

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 spotlessly clean. Enhanced cleaning routines were in place for high‑risk areas, and housekeeping staff received frequent compliments for their hard work in maintaining high standards of cleanliness. One person told us, “It’s very clean, the floor is washed daily.”

Infection prevention and control measures were well established. These included effective hand hygiene, appropriate waste disposal, regular disinfection of equipment, and clear procedures for managing outbreaks. We observed staff washing their hands and encouraging people to do the same before and after meals. Staff also wore appropriate personal protective equipment, such as aprons and gloves, when carrying out specific care tasks.

The provider carried out ongoing audits of infection prevention and control practices to ensure compliance. Audit outcomes demonstrated consistently high standards.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

People did not always have their medicines administered safely or at the right times.

We saw, 1 person could not have their prescribed medicine for 2 days because there were no stock and other people did not have their medicines and patches safely because the manufacturers’ directions were not followed properly.

Where people were prescribed medicines to be taken ‘when required’ or with a choice of dose, the protocols to support their administration were not detailed enough to ensure they were administered safely and consistently.

Some people needed to be given their medicines covertly, by hiding the medicines in food or drinks, but the information from a healthcare professional how to do this safely was not always available.

Where people were prescribed thickener to be added to their fluids, to help them swallow the fluids safely, we found the records showed, people’s fluids were not aways thickened to the correct consistency placing them at risk of aspirating and getting a chest infection.

Creams were not always managed safely. The creams listed on 1 person’s records did not match the creams that were in their bedroom. Another person’s cream had been recorded as applied for nearly 4 months, but the tube of cream showed minimal usage indicating the cream had probably not been applied as documented. Staff did not always have access to information about where to apply people’s creams and creams were not always stored safely.

One person’s diabetes was not always managed safely. Nurses were unaware how to access their historical blood sugar readings which meant they did not have full clinical oversight of the person’s diabetes. There was information recorded around safe blood sugar ranges and how to recognise and treat any episodes of hypoglycaemia or hyperglycaemia.

Medicines could not always be fully accounted for. Out of 5 stock checks made we found, 3 of them revealed, medicines could not be accounted for and this was mirrored in the daily stock check audits where it was recorded, stock adjustments had to be made. It is important medicines are accounted for to ensure they are administered as prescribed.

Most medicines were stored safely however the storage of waste medicines did not follow current guidance for safe storage.

We found no evidence that people were harmed at the time of the assessment because the harm is not always immediate. However, people were placed at increased risk of harm by not managing medicines safely. People felt they were receiving their medicines safely.

After the inspection and the feedback investigations were made into the concerns highlighted and an action plan was sent. This helped mitigate the seriousness of the concerns, but we had no evidence due to the timescales that the improvement has been embedded or sustained.