Tilford Care & Nursing 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 Good. At this assessment the rating has changed to 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 and treatment.

This service scored 59 (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, investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service recorded accidents and incidents, which were then reviewed and signed off by the registered manager. The registered manager’s review checked that all appropriate actions had been taken by staff. Accidents and incidents were analysed monthly to look for themes and trends, and changes made to reduce their recurrence. A professional had reported back to the service saying, “Your fact finding is of a good standard, covering all basis as well as sharing lessons learnt.”

Where people had several falls, they were referred to the GP or the falls team. In addition, some people had been moved to different rooms within the service as it had been determined that an alternate room would suit their needs better. This had proved beneficial to some people as their new rooms were nearer to the hub of the service, meaning people and staff were constantly walking by. A staff member said, “If there’s an incident, we document everything. If I found someone on the floor, I would call for help and would document everything exactly as I saw it. We might put sensor mats in place to alert us.”

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 registered manager used a pre-admission assessment to gather comprehensive information about people prior to meeting them. Their assessment was completed in conjunction with the hospital (if that was where people were residing), family members or the GP. This supported a holistic understanding of people’s needs and helped ensure continuity of care. A professional told us, “Assessments have been completed in a timely manner, and the service has shown flexibility in accepting individuals without delay, supporting effective hospital discharge processes. The home has maintained a professional and collaborative approach in working with adult social care, which has contributed to smooth care coordination.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff promoted people’s independence while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff understood their requirement to safeguard people, and as such they understood what constituted a safeguarding concern. Staff took safeguarding training prior to commencing at the service and undertook refresher training on the subject on an annual basis.

The registered manager knew when to raise safeguarding concerns with the local authority safeguarding team and told us, “We raised one just last week as someone received an injury from an unknown cause.” A staff member said, “Safeguarding is protecting people from abuse, from negligence and physical abuse. If you see someone with bruises or if people would jump when you went into their rooms, I would document and report to my front-line manager or senior.” Another told us, “We report to [deputy manager]. If they aren’t in, then the ops managers.”

Systems were in place to protect people’s rights under the Deprivation of Liberty Safeguards (DoLS). This helped ensure any restrictions were lawful, proportionate and regularly reviewed.”

A register of DoLS authorisations was maintained which enabled the registered manager to monitor any conditions in place and to submit re-applications as required.

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.

During our visit, we observed that staff did not always carry out suitable or safe moving and handling practices. We saw a staff member walk backwards holding a person’s hands, leading them into the dining/lounge area. Leading an elderly person while walking backwards is dangerous as it removes their visual cues, disrupts their natural centre of gravity, and creates a severe tripping hazard.

People had risk assessments within their care plan. These are related to identified risks for each individual. However, there was limited information in the risk assessments which meant staff did not always have the information needed to provide safe and effective care. This included where 1 person had asthma, and another person was on a gluten free diet. One person’s care plan recorded that they could reposition themselves when in bed, but went on to state that if they had not changed position enough, then staff were to support them to change position. However, it did not state what ‘not enough’ meant. Another person had a strict allergy to a particular food, and yet, this was not recorded in the information in the kitchen or in their nutrition and hydration care plan.

We also identified that people at risk of constipation were not being monitored. We reviewed the records for everyone living at the service and identified 4 people whose elimination records showed no bowel movement over several days, but staff had not identified this risk or taken appropriate action to respond.

Despite these concerns, we heard people felt safe living at the service. One person told us they felt safe, and their relative said, “The staff are lovely.” Another person said, “I feel safe. There are codes on the doors.”

Staff said their priority was to keep people safe by making sure, “We protect the residents and make sure they are safe, and we provide the care they need."

The provider did not always detect and control potential risks in the care environment.

During the morning, we found the laundry room door open for around 10 minutes without a member of staff inside. There was a bin bag in there with no cover or lid, filled with soiled clothes. There were also cleaning products which could have been accessed by an unauthorised person, placing people at risk of harm.

The environment was excessively warm throughout the day, with a relative commenting on the heat and a staff member offering to open the window in 1 person’s room whilst commenting on how warm it was. A radiator in a bathroom was also very hot during the entire visit. Another relative told us, “It gets very warm here.”

We found the environment to be poorly maintained in some areas, including a chipped skirting board, unstable pedestal drawer, damaged cabinet and chipped paintwork.

Although fire safety information was available, with each person having a personal emergency evacuation plan within the emergency fire bag in the event the building had to be evacuated, there was no information relating to 1 person living at the service. We fed this back to the registered manager on the day for their attention and action. These concerns meant people were not always protected from risks within the environment.

Following our site visit the registered manager provided us with a copy of the maintenance action plan, which demonstrated that a number of environmental issues had been identified for action. However, although the plan was dated January 2025, several actions did not have recorded completion dates, and some works had not yet been completed.

However, on the whole we found the premises were safe. Cupboards containing electrical equipment or hazardous items were locked and access to the stairs was key-coded. A full fire risk assessment was undertaken in March 2026 and actions arising from this had been completed by the provider.

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

Deployment of staff throughout our visit required improvement. Although we observed staff around, there were times people did not receive the support they required due to the deployment of staff. This resulted in at least 1 person’s meal sitting at lunch time for almost 15 minutes before they were supported to eat which meant they were not supported to eat in a timely and dignified way. We also saw 1 staff member supporting 2 people to eat at the same time, indicating there were insufficient staff to support people on an individual basis. In addition, we were on the first floor between 10:48 and 11:28 and no staff were around. It was only at 11:28 before a staff member came up routinely to check on people. A staff member told us, “There are no staff based there (on the first floor), but we do regular checks – hourly welfare checks.” Not everyone was able to use the call bell independently to alert staff, therefore this meant people were being left for a long time between checks.

We received mixed feedback about staffing levels from people, relatives and staff. Comments included, “There are enough staff, but they are always busy with other residents. They do come quickly if you need them. They are always walking around in groups (to which they showed us 3 staff who walked around together”, “There are not enough staff at night. They don’t stop people wandering into your room. I lock the door from the inside. There are no staff around and it scares me” and “Enough staff and she seems to be happy. On Friday we needed her moved from one seat to another and staff were there to do that.”

Some staff told us they felt rushed and were unable to have proper breaks during their shifts as there was no dedicated staff room. Staff said they did not have time to focus on people’s individual needs and where staff called in sick, agency was not always used to replace them, resulting in the day running short staffed. Other staff said, “There are enough staff and cover will be arranged if anybody is off” and “We have enough (staff) and night staff support people if they want to get up early. We have got enough time.”

Staff new to the service went through an established induction and training programme. This included a 2-day training induction day with tests at the end, then shadowing shifts for 1 to 2 weeks. There was an induction competency pack which the registered manager worked through with new staff, followed by probation periods for the first month and 3rd month. Staff who planned to administer medicines took appropriate training and were competency assessed by the provider’s clinical lead. A staff member told us, “I did moving and handling, 2 day training online and had a probation period. We have a link we can access for extra training and also regarding oral hygiene, dementia and how to handle them. We had shadowing for 7 shifts with a senior.”

Staff were recruited through robust processes. They provided evidence of previous employment, their fitness for the role, their right to work in the UK and underwent a Disclosure Barring Service check prior to commencing in the role.

The provider did not consistently assess or manage the risk of infection.

Infection control practices within the service required improvement. There was an odour of urine in parts of the building, and although staff told us they cleaned chairs after incidents where a person had soiled them, we observed a communal chair was not cleaned promptly following such an incident. A commode in 1 persons bathroom was visibly dirty and another person’s room had urine on the carpet. We also found a downstairs toilet bin had no bin bag and appeared stained with used gloves inside it, and another toilet had a full bin with used continence pads. The door of that toilet was left open on several occasions, causing a strong malodour in the corridor.

Staff told us they used a ground floor communal toilet to clean people’s continence aids. They said this toilet was not used by people. However, we saw staff take people into it, and we noticed in another communal bathroom, staff were using empty incontinence pad packets as ‘bins’. These were hanging up and full of various items of rubbish. Some people’s rooms had stained equipment or smelled strongly of urine. These concerns increased the risk of the spread of infection and demonstrated ineffective infection prevention and control practices. Despite these concerns, people and relatives gave positive feedback about cleanliness.. One person said, “They clean my room every day” and a relative saying, “The property is kept clean throughout.”

Staff were provided with personal protective equipment (PPE) to support them to carry out their role. We observed staff wearing aprons and gloves during lunch and for personal care. A staff member said, “We use gloves and aprons for personal care.”

The service had an infection, prevention, control (IPC) policy in place. A staff member told us they followed good practice when providing personal care and handling soiled clothes. They said, “In morning personal care we will put things in a white bag and then in yellow bag. We will wash hands and then apply alcohol gel. Soiled things go in a red bag.”

The provider did not consistently ensure that medicines and treatments were managed safely.

Staff did not always follow good practices when dispensing people’s medicines. We observed a staff member go to a person during their lunch with a small pot with the person’s tablet in. They tipped the tablet onto a spoon for the person to take, the tablet fell on the table. Instead of scooping it up with the spoon, the staff member picked it up with their fingers and put it in the person’s hand. This went against basic medication hygiene and contamination-control procedures.

We discovered 3 people did not receive all of their prescribed morning medicines, placing them at risk of harm. We also observed 1 person being given a liquid medicine, which dripped down the side of their neck. They told us they were wet all over, and although the staff member offered the person a paper towel, they did not take the time to offer them a damp cloth to enable them to clean themselves properly.

Where people used topical creams (medicines in cream format) staff were not consistently completing records relating to their application. Of the 13 medicine records we reviewed, none of the body maps had been completed to show where staff should apply these creams. We raised our observations with the registered manager who took action to address all these shortfalls immediately following our visit.

Despite these concerns, we found staff were carrying out regular stock checks of medicines and they regularly cleaned the medicines room. People’s medicine administration charts contained important information about a person, such as allergies, their GP details and guidance for medicines which could be crushed or taken with food. Staff recorded exact times medicines were given where the person needed to have them at a specific time.