Background to this inspection
Updated
13 November 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was undertaken by three inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Tillson House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service did not have a manager registered with the Care Quality Commission. A manager had been appointed and had applied to be registered with the Care Quality Commission. This meant that the provider was legally responsible for how the service was run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We took this into account when we inspected the service and made the judgements in this report. We used all this information to plan our inspection.
During the inspection
We spoke with four people who used the service and nine relatives of people who used the service about their experience of the care provided. We spoke with eleven members of staff including the manager, deputy manager, seven care and support staff and two housekeeping staff.
We reviewed a range of records. This included five people’s care records and seven people’s medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
Updated
13 November 2021
About the service
Tillson House is a residential care home providing accommodation and personal care to 30 people aged 65 and over at the time of the inspection. The service can support up to 40 people across two floors.
People’s experience of using this service and what we found
People’s individual risks were managed in a safe way and environmental risk assessments were completed appropriately.
People were supported by a staff group who had been trained in safeguarding and understood how to safeguard vulnerable adults from abuse and neglect.
The provider had enough staff with the right skills deployed to provide people with their commissioned care.
Medicines were safely managed. Medicines administration record (MAR) charts were accurately completed, medicines were safely administrated and when people received their medicines ‘as and when required’ the correct protocols were in place.
The provider demonstrated they learnt lessons when things went wrong and they encouraged continuous improvements.
Effective infection prevention and control (IPC) policies and procedures were in place and the service was following best practice and Government guidance in relation to the management of COVID-19 and other infections.
Quality control systems were effective in identifying issues within the service. When issues were identified during audits, the provider developed effective action plans to improve care and drive continuous learning.
Care records were person-centred and contained sufficient information about people’s preferences, specific routines, their life history and interests.
People and their relatives were involved in developing and reviewing their care plans and risk assessments. People’s relatives and staff felt they were able to contribute to the development of the service.
The provider and management team had good links with the local communities within which people lived.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was requires improvement (published 4 June 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We received concerns in relation to staffing, staff culture and neglect of people using the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe and well-led sections of this full report.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Tillson House on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.