CQC report explained · a nursing home
What the CQC found at Tandridge Heights
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2021
Rated Good overall, with Safe rated Good but Well-led Requires Improvement because checks did not always find safety issues.
This was an unannounced inspection on 20 November 2020. Inspectors spoke with people using the home, relatives and staff. They reviewed care records, medicines records, recruitment files, training information and management records.
The home was clean and infection control arrangements were mostly good. People said they felt safe. Inspectors found suitable risk assessments, safe medicines administration, enough staff during the visit and appropriate safeguarding procedures.
The home was rated Requires Improvement for Well-led. Quality checks had improved, but they had not found out-of-date emergency diabetes products or bedroom doors being held open in a way that could create a fire risk. Some staff also said they felt worried about admitting mistakes.
The overall rating stayed Good, the same as at the previous inspection. The Safe rating stayed Good, while Well-led remained Requires Improvement. The other three question ratings were not inspected at this visit and were carried over from the previous comprehensive inspection.
People felt safe
People and relatives gave positive feedback about safety and care. Staff knew how to recognise and report abuse.
“People told us they felt safe living in the service.” from the report
Clean and good infection control
The home was clean, tidy and free from bad smells. Inspectors found staff generally using protective equipment and following infection control processes.
“The service was clean, tidy and odour free.” from the report
Clear risk planning
Care records gave staff guidance about individual risks, including nutrition, skin care and movement. Records were reviewed when people's needs changed.
“People's records contained clear guidance for staff to minimise known risks.” from the report
Person-centred care
Care was adapted to people's wishes and preferences. Inspectors saw examples of people being supported to make choices and remain as independent as possible.
“Person-centred care was delivered and tailored around people's needs, wishes, choices and preferences.” from the report
Out-of-date emergency products
needs fixingAn emergency diabetes grab bag contained out-of-date products. Staff removed and replaced them during the inspection.
“Although medicines were stored safely with processes in place to remove any that were out of date we found an emergency diabetic grab bag containing products used to raise blood glucose which were out of date.” from the report
Fire door checks
seriousSeveral bedroom doors were held open with objects. Inspectors said this could create a fire safety risk, and the manager said it would be corrected immediately.
“We found several bedroom doors propped open with objects which could be a fire safety risk.” from the report
Staff confidence in reporting mistakes
minorSome staff said they felt worried about admitting mistakes. The manager said they would speak with staff to help them feel able to speak openly.
“Some staff we spoke to said they felt worried about owning up to mistakes, but they would report to the registered manager if something went wrong.” from the report
- 01What checks now make sure emergency diabetes products are always in date?
- 02How have you stopped bedroom doors being propped open and made sure fire door closers are used correctly?
- 03What has been done to help staff feel safe reporting mistakes and concerns?
- 04What action has been taken since inspectors said the quality assurance checks did not find all problems?
- 05How are infection control arrangements, including extra protective equipment when helping people eat and drink, being monitored?
This was a focused inspection of Safe and Well-led, including infection prevention and control; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 28 January 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2019
Rated Good overall; inspectors found safe, kind and personalised care, but the home was not always well-led and records needed improvement.
This was an unannounced inspection on 09 October 2019. Inspectors spoke with people, a relative and staff. They reviewed care records, staff files, complaints, incidents, training records and quality checks.
The home was rated Good for Safe, Effective, Caring and Responsive. People were supported safely, received their medicines correctly, enjoyed the food and activities, and received care that was tailored to their needs. Staff were described as kind and respectful.
Well-led was rated Requires Improvement. Some care records were incomplete or inaccurate, and the home's audits had not found one out-of-date diabetic medicine item. The provider was no longer in breach of regulations from the previous inspection, and records were addressed after inspectors raised the issues.
Safe care and medicines
Staff understood people's risks and had training to give medicines safely. There were systems for responding to incidents and learning from them.
“Staff followed best practice when administering medicines to people.” from the report
Kind and respectful staff
People spoke positively about staff, and inspectors saw caring interactions. Staff supported privacy, dignity, independence and people's individual ways of communicating.
“We made observations of pleasant caring interactions.” from the report
Personalised care
Care plans had improved and included people's routines, interests, backgrounds and health needs. Staff were seen following these plans and involving people in their care.
“Care plans had been reviewed and updated to include more personalised detail about peoples' needs as well as their backgrounds and preferences.” from the report
Activities and community links
People could take part in varied activities, outings and events. The home also worked with local groups and community services.
“Activities covered a range of interests and hobbies with quizzes, arts and crafts and entertainment.” from the report
Incomplete care records
needs fixingSome records were not accurate or up to date. Examples included missing life histories and inaccurate falls monitoring records, although inspectors said staff practice was consistent and care was not affected.
“Some records were not accurate and up to date.” from the report
Audits did not find every problem
needs fixingThe home carried out audits, but these had not identified an out-of-date diabetic medicine item. Inspectors recommended improving the quality checks.
“Whilst these took place regularly and identified actions, they had not picked up the out of date diabetes medicines reported on in Safe.” from the report
- 01How are you checking that care records accurately reflect the care each person receives?
- 02What changes have you made to your audits since inspectors found that they had not identified out-of-date diabetic products?
- 03How do you make sure people's life histories, communication needs and personal preferences are recorded and kept up to date?
- 04How are you monitoring the improvements made since the previous inspection?
- 05How do residents and relatives know that their feedback has led to changes in care or activities?
This was a planned, unannounced inspection covering all five key questions, with the inspection prompted by the previous Requires Improvement rating. This explanation was written from the published report of 23 November 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Tandridge Heights
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- January 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- October 2018Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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