Tilford Care & Nursing 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 Good. At this assessment the rating has changed to Requires Improvement

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 61 (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 did not always have 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 provider had a vision and set of values focused on transparency, equality and person-centred care. However, these were not always consistently reflected in practice.

Feedback from people, relatives, professionals and staff was generally positive. People told us they felt comfortable and well looked after, and relatives and staff described the service as well run. Feedback included, “She’s comfortable and well cared for. It’s a good establishment”, “They are friendly. The manager is nice” and “We are extremely happy with the care, kindness and compassion our mother receives.”

However, during our visit we observed some poor staff practices, which did not always align with the provider’s stated values. The registered manager told us they responded to complaints promptly and regularly shared compliments with staff to promote a positive culture.

The provider did not always have 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 provider had leaders who were well regarded by people, relatives, staff and professionals. Feedback indicated leaders were approachable, supportive and responsive. Staff felt well supported and worked well as a team. External professionals described the management team as engaging and adaptable in meeting people’s needs.

However, we identified some areas of practice during our visit that did not consistently reflect the provider’s values, indicating that leadership oversight was not always effective in embedding these across the service.

The registered manager understood the need to submit notifications to CQC in the event of an incident, accident or safeguarding concern, however. This is a statutory requirement of registration with the commission.

Positive feedback received from people, relative’s, staff and professionals included, “The manager is a nurse and she runs like a business with a heart”, “I have been very impressed by management and staff in every respect”, “I really like the deputy manager and she is very good. She is more like the manager at times as we see a lot of her” and “As a Surrey contract relationship lead for this care home provider, I work closely and collaboratively with [registered manager] and the management tea. I have found them to be very engaging, responsive and willing to adapt to support Surrey council funded residents’ care needs.”

Staff did not consistently feel able to speak up or that their voice would be heard despite the provider having robust processes and systems in place to encourage staff to raise any concerns or complaints.

Some staff told us they did not always feel able to speak up. They said they had raised issues such as a lack of staff room several times, but were told this was down to budget restraints. They said these responses came from senior management, rather than the in-house management. Other staff said it was not always easy to raise concerns as some staff were related. They were deterred from raising concerns as they were always asked to put these in writing for head office to investigate. This meant staff did not always feel confident raising concerns.We were also told by staff that if a staff member phoned in sick, there was a no-agency policy from management and this could leave them short staffed on these occasions and rushed.

However, some staff told us they felt able to speak up, telling us, “I can go to management at any time” and “I feel valued. I can go to the nurses and the management team. When you have been here so long, you form those relationships.”

The provider valued diversity in their workforce. promoted an inclusive and fair culture by supporting equality and equity within the workforce. This supported staff to work effectively in their roles and contributed to a positive working environment. Staff were treated fairly across the service. The registered manager told us, “Recruitment goes through head office, so I don’t know much about applicants at that stage. As a result, I treat everyone equally during the interview process. We support staff in a variety of ways.”

They went on to explain how individual support had been provided to staff members with different needs, including 1 with a learning disability, another with a neurological condition, and a third with a health-related issue. The registered manager described how adjustments had been made, such as changing shift patterns, providing suitable equipment, and presenting paperwork in a more accessible format to enable staff to carry out their roles effectively.

The service had also recruited several staff members from overseas. Where English was not their first language, the provider supported them by arranging English language lessons to help them develop their communication skills and confidence in the workplace. Staff felt equally treated. They told us, “When I first came everyone was very good and helpful and we can talk to a senior if we need anything. We can make requests for anything different (like flexible working). We are from different countries, but we are here to take care of them (people)”, “There is no difference between day and night staff. We are all a team. We are all on the same level and treated well” and “Our management do well at celebrating everyone.”

The provider did not consistently have effective governance systems, clear accountability or robust oversight of risk, performance and outcomes. This indicated a lack of oversight and failure to act on potential indicators of risk. Management oversight was not always effective in identifying any shortfalls in care and record keeping. For example, systems had not identified that staff were not consistently monitoring and recording people's bowel movements in line with their assessed needs. In addition, management were not sufficiently monitoring staff to check they were always following safe moving and handling practices. We also found that several people’s risk assessments lacked sufficient detail and guidance for staff, limiting their effectiveness. These concerns had not been recognised through the provider's quality assurance and monitoring processes.

Records relating to people's care required improvement. Staff were not always recording sufficient information about people's food and fluid intake to enable effective monitoring. For example, 1 person's records stated they had eaten all of their breakfast, but did not specify what it was that they had eaten. Similar entries were recorded for lunch. On a different day, no information had been recorded for the person's evening meal, and staff had used entries such as "yes" against breakfast and lunch without again providing any detail about what had been eaten. This meant staff and managers could not effectively monitor people’s nutritional intake or identify potential risks. Monitoring records relating to people's weight were not always robust. One person had experienced consistent weight loss throughout April 2026 and had been weighed weekly; however, records showed they had not been weighed since 24 April 2026 despite the identified concern. Another person was also on weekly weight monitoring, but this ceased on 19 April 2026. We also noted an increase in this persons weight from 48.8kg to 57.9kg within 1 week. There was no evidence that this significant increase had been identified or investigated to establish whether it resulted from a recording or weighing error.

Care plans did not always provide staff with sufficient information to help ensure they could meet people's needs effectively. End-of-life care plans contained limited information about people's wishes, preferences or choices for this stage of their lives. Other people were living with specific health conditions, including chronic obstructive pulmonary disease (COPD), anxiety and depression; however, there were no condition-specific care plans to help staff understand how these conditions affected individuals and what support they may require. We also found examples where care plan guidance was not being followed in practice. For example, 1 person's care plan stated their walking aid should be kept within easy reach, yet we observed them sitting in the lounge without access to it. This indicated a lack of meaningful engagement and oversight of people’s social needs. Where people had positive behaviour support (PBS) documentation this was also lacking in detail. One person's PBS plan contained information about activities they enjoyed, such as films, sports and card games, but did not provide guidance for staff on how to recognise, prevent or respond to periods of agitation or distress. This meant staff did not have clear information to support a consistent approach when the person became unsettled.

Daily care records were generally task-focused, brief and lacked meaningful detail. Entries often recorded that care tasks had been completed but provided little insight into people's wellbeing, mood or how they had spent their day. As a result, the overall narrative of people's lives lacked personalisation and did not consistently demonstrate person-centred care.

Although governance systems were in place, they were not always effective in identifying and addressing these concerns. The registered manager told us, “Certain things are checked monthly, while other areas have different timescales and frequencies. Senior manager will review the audit and comment, but generally by the time this is done, we have already actioned any shortfall.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The provider worked in partnership with other services to help ensure people received coordinated and joined-up care. The service worked effectively with external agencies such as the GP practice, district nurses, tissue viability nurses and dietitians, supporting people to access care and treatment when they needed it.

The registered manager was a member of Skills for Care, the Surrey Forum and the CQC Forum. This supported them to remain up to date with best practice, share learning with others and access training and guidance to support continuous improvement.

However, there were opportunities to further develop links with the local community. Strengthening these links would help ensure people had greater opportunities for engagement and support their wellbeing by enabling them to participate in activities that reflected their interests and preferences.

The provider continually learned to encourage improvements across the organisation and local system. However, there were further opportunities to identify and embed these improvements to demonstrate a proactive, rather than reactive approach.

During our inspection, we found that any shortfalls or concerns identified were taken seriously by management, who were open and responsive to feedback. There was a clear willingness to reflect on practice and make improvements where required. Following our visit, the registered manager provided us with a detailed action plan outlining the steps they intended to take to address the areas highlighted during the inspection and improve outcomes for people using the service. This responsiveness was echoed by a social care professional who had told the service, “You engage greatly with quality assurance, very responsive when we make contact and take on board/implement recommendations where given.” This demonstrated a positive approach. However, as highlighted in this key question, there was further work needed on governance systems to help ensure that shortfalls were identified and addressed by management at the earliest opportunity, so that improvements to the quality, culture, and overall performance of the service were driven internally through effective oversight and continuous monitoring.

The service was actively exploring ways to enhance the quality of care provided. Planned improvements included the introduction of electronic medicines records to strengthen medicines management. In addition, the provider was considering the use of unobtrusive in-room monitoring technology to support people's safety while maintaining their privacy and independence. These developments demonstrated an ongoing focus on innovation and improving service delivery.