CQC report explained · a nursing home
What the CQC found at Tanworth Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- The targeted check found improved risk assessments, medicines management, environmental safety and infection control. The full Safe rating was not reviewed and remained Requires Improvement from the previous inspection.
- Effective?
- Good
- This area was not assessed in this targeted inspection.
- Caring?
- Good
- This area was not assessed in this targeted inspection.
- Responsive?
- Good
- This area was not assessed in this targeted inspection.
- Well-led?
- Requires improvement
- The targeted check found better oversight, regular audits and action to improve standards. The full Well-led rating was not reviewed and remained Requires Improvement from the previous inspection.
What inspectors found, November 2022
Overall rating remains Requires Improvement; a targeted inspection found improvements in risk management and oversight, but did not give new ratings.
This was an unannounced targeted inspection on 8 June 2022. Inspectors checked whether the home had acted on warning notices about safe care, treatment and management systems. They spoke with people, relatives and staff, and reviewed support plans, medicines records and management documents.
Inspectors found that risks to people, medicines and the environment were being assessed and managed better. They found safe medicines processes, suitable support for eating and drinking, and appropriate infection control measures. People were supported in a clean and well-maintained environment.
The home had also improved its checks and oversight. The manager reviewed audits and took action when issues were identified. However, this was a targeted inspection, so it did not reassess every area of care. The overall rating remains Requires Improvement, while the areas inspected were marked Inspected but not rated.
Improved risk management
Risk assessments covered people's health, behaviour, daily activities and the environment. Staff knew when to report changes and seek professional advice.
“Risk assessments were individualised to people's needs, covering environment, health, behaviours, social interaction and daily activities.” from the report
Clean and safe environment
People were supported in an environment that inspectors found safe, clean and well maintained. Infection prevention arrangements were also found to be suitable.
“People were supported in a safe, clean and well-maintained environment that met their needs.” from the report
Stronger oversight
The home had regular checks covering areas such as health and safety, infection control and safeguarding. The manager reviewed these checks and acted on trends.
“The provider had systems in place to monitor and improve standards and safety and the registered manager reviewed these regularly to identify trends and took actions to make improvements.” from the report
Full service rating remains Requires Improvement
needs fixingThe previous inspection found problems with risk management and oversight. Although the targeted inspection found these specific issues had improved, the overall rating was not changed.
“The overall rating for the service has not changed following this targeted inspection and remains requires improvement.” from the report
The inspection was limited
minorInspectors did not review the whole Safe or Well-led areas, and did not assess Effective, Caring or Responsive. The report therefore does not show whether the wider service had improved.
“Targeted inspections do not change the rating from the previous inspection.” from the report
- 01What evidence can you show that the improvements in risk assessments and medicines management have been maintained?
- 02How are audits reviewed now, and what happens when they identify a problem?
- 03What were the outcomes of the next full inspection after this targeted visit?
- 04How are people's changing health needs, nutrition and hydration risks recorded and reviewed?
- 05When will the other areas of care, including Caring, Responsive and Effective, be fully assessed?
This was a targeted inspection of specific concerns under Safe and Well-led; it did not assess the whole key questions or the Effective, Caring and Responsive areas, so previous ratings remained in place. This explanation was written from the published report of 12 November 2022 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, April 2022
Rated Requires Improvement; inspectors found risks and oversight were not always managed well, with warning notices issued.
This was an unannounced focused inspection on 3 March 2022. Inspectors reviewed safety and leadership because concerns had been raised. They spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was not always safe. Records did not consistently show that risks such as choking, dehydration and pain were being managed. There were also problems with covert medicines, medicines given when needed, an unsafe laundry chute area and staff wearing masks incorrectly.
The home’s checks did not reliably find or resolve these problems. Inspectors found breaches of the rules on safe care and treatment and good governance. The overall rating changed from Good at the previous inspection to Requires Improvement. The other three questions were not inspected during this visit and carried over their previous ratings.
People felt safe
People and relatives generally said people were safe, and staff understood how to report safeguarding concerns.
“I feel safe, the staff make it safe for me.” from the report
Safe recruitment and support
Staff recruitment followed the provider’s procedure. Staff also said they received support and guidance through individual and team meetings.
“Staff were recruited safely in line with the providers procedure.” from the report
Infection controls
Inspectors were assured about visitor controls, testing, admissions, hygiene, outbreak arrangements and the infection prevention policy.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Improvements had started
The management team had begun updating care plans, training staff in record keeping and using a trainer to support new staff.
“A trainer was working, alongside new staff to offer support and practical, training to demonstrate and embed good care practices.” from the report
Care risks were not always managed
seriousRecords did not clearly show that pain and fluid intake were monitored. Staff also had different knowledge about the prescribed thickener for one person at risk of choking.
“This posed a risk of them choking.” from the report
Medicines records were incomplete
seriousThere was no guidance for staff on administering three people’s covert medicines. One person also had no clear protocol for medicines prescribed as needed.
“Records contained no guidance to instruct staff about the safe way to administer these medicines.” from the report
Environmental safety risk
seriousAn unlocked laundry chute area contained cleaning liquids and had an unprotected hatch. The manager fixed the door during the inspection.
“This unlocked room also contained containers of cleaning liquids which could pose a risk of harm to people.” from the report
Quality checks missed problems
seriousThe home’s monitoring systems did not find all the safety and medicines issues. Problems with record keeping had also been identified previously but were not resolved.
“Where governance systems had identified concerns, action taken did not always resolve the issues such as poor record keeping.” from the report
Staffing pressure
needs fixingPeople and staff gave mixed views about whether there were always enough staff. The provider was recruiting and using regular agency staff to address vacancies.
“Staff are very good but focused on supporting me, they have limited time to spend with me, for a chat” from the report
Masks were not always worn correctly
needs fixingInspectors saw staff wearing masks below their noses on several occasions. The manager reminded staff about using protective equipment correctly.
“On numerous occasions we saw staff wearing their face masks below their noses.” from the report
- 01What has been done to make sure each person’s choking, hydration and pain risks are clearly recorded and monitored?
- 02How are covert medicines and medicines prescribed as needed checked, and where can we see the current instructions for staff?
- 03How will you prove that environmental checks now identify risks such as unlocked areas, faulty locks and cleaning products?
- 04What changes have been made to record-keeping training and quality checks since this inspection, and how do you know they are working?
- 05How many staff are usually on each shift, including agency staff, and how are vacancies affecting the time available for residents?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried forward from the previous inspection. This explanation was written from the published report of 29 April 2022 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 Tanworth Court
2 rated inspections over a year: the service has slipped, from Good to Requires improvement.
- November 2022Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
- April 2022Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2021GoodSafe: GoodWell-led: Good
- January 2020
Registered with the Care Quality Commission on 7 January 2020.
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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