CQC report explained · a residential care home
What the CQC found at Tarry Hill
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Some medicine records did not include required information, and risk reviews were not always added to care plans. Inspectors found enough staff and effective safeguarding and infection control arrangements.
- Effective?
- Good
- Staff had completed relevant training and people were supported with healthcare, food, communication and decision-making. This rating had improved from Requires Improvement at the previous inspection.
- Caring?
- Good
- Staff knew people well and supported their dignity, privacy, independence and choices. The rating had improved from Requires Improvement at the previous inspection.
- Responsive?
- Good
- Care was personalised and relatives were involved. People were supported to communicate, maintain relationships and take part in activities that suited them.
- Well-led?
- Good
- The home had open leadership, governance systems and a person-centred culture. However, medicine audits had not identified the recording concerns found during the inspection.
What inspectors found, January 2022
Rated Good overall; inspectors found kind, person-centred care, but medicines records and some risk records needed improvement.
The inspection was unannounced and took place on 11 January 2022. Inspectors spoke with people, relatives and staff. They observed interactions and reviewed care records, medicine records, staff files and management records.
The home was rated Good overall. Effective, caring, responsive and well-led were all rated Good. Safe was rated Requires Improvement because some medicine records and risk information were not complete or up to date.
The report says the home had improved since the previous inspection, when it was rated Requires Improvement. The provider was no longer in breach of Regulations 9, 12, 17 or 18, although inspectors still found areas that needed attention.
Kind and respectful care
Inspectors saw staff spending time with people and supporting their privacy, dignity and independence. Relatives gave mainly positive feedback.
“People were supported by staff who were kind and caring.” from the report
Enough trained staff
There were enough suitably trained staff on duty to meet people's needs. Staff had induction, supervision and competency checks.
“There were enough suitably trained staff on duty to meet people's needs.” from the report
Personalised support
People's preferences, beliefs, communication needs and lifestyles were recorded and respected. Staff supported people to make choices and live as they wished.
“People's individual needs, preferences, beliefs and lifestyle choices were known, valued and respected.” from the report
Medicine records
needs fixingRecords did not always show when medicines had been taken or include protocols for medicines given only when needed. Some handwritten records had not been checked by two staff as required by guidance.
“The systems for recording when people had taken their medicines were not always in line with national guidelines.” from the report
Risk information
needs fixingRisk assessments had been reviewed, but the latest information was not always included in care plans. This could mean newer staff did not have the clearest guidance.
“The documented risks in people's care plans were not always reviewed and updated in response to changes in people's needs.” from the report
Audits missed medicine issues
needs fixingThe home’s medicine audits did not identify the recording concerns found by inspectors. The manager said the audit process would be reviewed.
“The medicine audits completed in each of the five homes had failed to identify the few concerns with medicines identified at this inspection.” from the report
Dignified communication
minorSome staff had previously been heard speaking to people in an undignified way. The manager addressed this and arranged training.
“There had been some occasions where some staff had been heard speaking with people in an undignified way.” from the report
- 01How have you checked that medicine records now show the time each medicine was taken?
- 02Are protocols now in place for all medicines given only when needed?
- 03How do you make sure the latest risk assessments are included in each person’s care plan?
- 04What changes have been made to medicine audits since inspectors found they had missed recording concerns?
- 05What training and checks are now used to make sure staff speak to people with dignity and respect?
This was an unannounced inspection covering all five key questions, including infection prevention and control and the home’s approach to Right support, right care, right culture. This explanation was written from the published report of 29 January 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, October 2020
Tarry Hill was rated Requires Improvement; safety, staff training and management systems still had important weaknesses, although the rating improved from Inadequate.
Inspectors visited without warning on 27 and 28 August 2020. They spoke with people, relatives, staff and outside professionals. They reviewed care records, medicines records, staff files and management records.
The home had improved since the previous inspection, but inspectors found people were still at risk. Risk information was not always clear or up to date. Medicines were not always managed or recorded safely. Staff training was not sufficient, and checks on the quality of care did not find important problems.
The overall rating improved from Inadequate to Requires Improvement. The home was no longer in special measures, but it remained in breach of three regulations. This focused inspection only assessed Safe, Effective and Well-led. The other ratings carried over from the previous comprehensive inspection.
Improved safeguarding practice
The report says restraint, seclusion and segregation were being used only as a last resort. Safeguarding improvements had been made since the previous inspection.
“Since the last inspection the registered manager had implemented improvements and restraint, seclusion and segregation were now only used as a last resort.” from the report
Choice over food and drink
People could choose what they ate and drank. Food and drink were stored and prepared in line with people's cultural beliefs.
“People exercised choice over their food and drink options and were supported to eat and drink what they wanted.” from the report
Clean surroundings
Inspectors found the home was clean and did not have unpleasant smells.
“Throughout the inspection the homes appeared clean and were free from malodours.” from the report
Better mental capacity practice
People were supported to make decisions, and restrictions on liberty were in line with the conditions recorded.
“Where people were deprived of their liberty this was in line with the conditions set out in their DoLS and the least restrictive option was used.” from the report
Medicines were not consistently safe
seriousSome staff working at night were not trained to recognise when people might need medicines as required. Records did not always explain why medicines were given, and one medicine was missing from the medicines record.
“The registered provider did not always follow relevant national guidance around the administration and recording of medicines.” from the report
Risk and infection plans were unclear
seriousSome risk plans were out of date or did not give staff clear instructions. Inspectors also found that not all staff wore the correct protective equipment for Covid-19.
“Risk management plans for the spread of Covid-19 did not provide staff with clear, up to date guidance about this.” from the report
Staff training was not sufficient
seriousThe provider did not ensure staff were trained and supervised before completing mandatory training. Only eight staff had completed communication training, and online training did not always check competence.
“The provider had failed to ensure staff received appropriate training to enable them to carry out the duties they were employed to perform.” from the report
The environment felt institutional
needs fixingThe home had five houses close together, with staff moving between them. Inspectors found that some areas were noisy, not personalised and did not give people enough quiet space.
“This made the service feel more like a campus and created an institutionalised and less homely feel.” from the report
Quality checks missed important problems
seriousThe provider's monitoring systems did not identify concerns with medicines, staff training or the environment. Some care records were incomplete, inconsistent or referred to the wrong person.
“The systems and processes the registered provider used to assess the safety and quality of the care people received were not effective.” from the report
High staff turnover
needs fixingRelatives and staff said there had been many staff changes and considerable use of agency staff. This meant people were not always supported by staff they knew and trusted.
“There are a lot of agency staff and a lot of staff change, this upsets [Name].” from the report
- 01What has changed in medicines training, night-time cover and medicines records since the inspection?
- 02How do you now make sure every staff member has completed the training and supervision needed before working unsupervised?
- 03What steps have you taken to reduce agency use and staff turnover, and how do you keep support consistent for each person?
- 04How have you improved Covid-19 infection control, including mask use and areas for putting on and removing protective equipment?
- 05How are you checking that risk plans, care records and quality audits are complete, accurate and up to date?
This was an unannounced focused inspection following earlier breaches and covered Safe, Effective and Well-led only; Caring and Responsive were not assessed and their ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 2 October 2020 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 Tarry Hill
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- January 2022Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2020Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- December 2019Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2018Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2017
Registered with the Care Quality Commission on 7 March 2017.
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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