CQC report explained · a residential care home
What the CQC found at Teignbridge House Care Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2024
Rated Requires Improvement and still in special measures; the well-led rating was Inadequate, with serious safety and management weaknesses.
This was an unannounced inspection on 7 and 8 November 2023. Three inspectors spoke with people, relatives, staff and health professionals. They examined care records, staff files, medicines, complaints, incidents, accidents, health and safety records, and management checks.
Some improvements had been made since the last inspection. Staffing levels, infection control, fire safety, activities, complaints handling and the culture of the home had improved. People and relatives generally said staff were kind and people felt safe and well cared for.
However, important risks were still not managed reliably. Records for pressure care, bowel monitoring, weight, food and fluids were incomplete. Care plans contained errors, some staff lacked required training and supervision, and people's legal rights around consent were not always protected. Management checks had failed to find or fix these problems.
The overall rating improved from Inadequate to Requires Improvement. Caring was rated Good. Safe, Effective and Responsive were Requires Improvement, while Well-led remained Inadequate. The home remains in special measures because it has had an Inadequate rating in a key area over two consecutive comprehensive inspections.
Kind and respectful care
People and relatives gave positive feedback about the care. Inspectors saw staff treating people with dignity and responding when someone appeared overwhelmed.
“We observed staff being mindful of people's dignity.” from the report
Health professional links
Health professionals said staff shared information and acted on advice. People were supported to access healthcare services.
“I have full confidence that any health needs will be reported, and any plans I suggest will be actioned.” from the report
Staffing improvements
Staffing levels had increased during busy afternoon periods and rotas matched the home's dependency assessment. Inspectors saw staff helping people calmly and without rushing.
“We saw staff assisting people in an unhurried and calm manner.” from the report
Activities and family involvement
People could join group and individual activities, hobbies and outings. Families were supported to visit and take part in care.
“Various opportunities were available for people to interact socially and take part in group and individual activities and hobbies.” from the report
Health risks were not reliably monitored
seriousRecords for pressure care, bowel management, weight, food and fluids had significant gaps. This included risks affecting people with catheters and people needing support with nutrition.
“Risks were not always monitored or well managed.” from the report
Safeguarding concerns were missed
seriousStaff did not always recognise possible abuse or unexplained injuries, and required records and referrals were not always made.
“The provider had failed to ensure systems and processes to safeguard people were effectively operated.” from the report
Consent and restrictions were not handled lawfully
seriousMental capacity assessments and best-interest decisions were missing or unsuitable for some people. Some restrictions were used without the required process.
“People's rights were not always protected.” from the report
Care plans contained errors
seriousSome care plans gave incorrect information about the help people needed and did not explain how to support emotional distress, anxiety or breathlessness. Reviews did not always record changes.
“Care plans did not always reflect people's needs and personal preferences.” from the report
Training and supervision were incomplete
seriousOnly four staff had completed dementia awareness training, some staff had large gaps in their training records and no one-to-one supervision had taken place.
“Staff did not always receive appropriate training and supervision.” from the report
Management checks did not drive improvement
seriousAudits failed to identify several important problems, and actions recorded as complete had not always been done. The provider's systems did not give managers reliable oversight of people's risks.
“Systems were not effective to ensure good governance of the service.” from the report
- 01How are you now recording and checking repositioning, skin checks, bowel care, weight, food and fluid intake for each person?
- 02What has been done to ensure every care plan is accurate, personalised and reviewed when people's needs change?
- 03How are mental capacity assessments, best-interest decisions and Deprivation of Liberty Safeguards applications being checked?
- 04How many staff have now completed dementia training, individual health-needs training and one-to-one supervision?
- 05Who is currently legally responsible for the home, and how are managers checking that audits lead to completed actions?
This was an unannounced inspection prompted by concerns about people's health needs and focused on the related risks; it did not examine the circumstances of the reported death, which was subject to a separate CQC investigation. This explanation was written from the published report of 12 January 2024 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, July 2023
Teignbridge House Care Home Limited was rated Inadequate and placed in special measures after inspectors found serious safety, staffing and management failures.
Inspectors visited on four days in May 2023. They spoke with people living at the home, relatives and staff, reviewed care and medicines records, checked staff files, toured the building and observed care. The inspection began as focused but was expanded to a comprehensive inspection because of the concerns found.
The home was not consistently safe. Risks involving fire safety, infection control, pressure damage, dehydration and malnutrition were not properly assessed or monitored. Safeguarding concerns were not dealt with or reported properly. Recruitment, staffing levels, staff training and support were also not good enough.
Care was sometimes kind, and people said staff knew them well. Food preferences were catered for and medicines were generally given as prescribed. However, care records did not properly reflect people's wishes, emotional needs, consent or best-interest decisions. Complaints, including repeated problems with missing laundry, were not recorded or handled effectively.
The overall rating fell from Requires Improvement in 2019 to Inadequate. The home was in breach of several regulations, including two breaches that had continued from the previous inspection. It was placed in special measures while CQC monitors whether significant improvements are made.
Kind staff interactions
People and relatives generally described staff as friendly and caring. Inspectors also saw staff taking time to reassure people and include them in activities.
“We saw caring and thoughtful interactions by some staff members.” from the report
Food preferences
The home asked people about their likes and dislikes. Relatives said staff tried different foods and snacks to encourage people who ate little.
“People's individual tastes and preferences were catered for.” from the report
Medicines usually given correctly
Medicines records showed people generally received their medicines as prescribed. People and relatives were positive about how medicines were administered.
“These records showed that people's medicines were given as prescribed for them.” from the report
Staff knew people well
People said staff recognised when they were unwell or in pain. Relatives were confident staff would contact health professionals when needed.
“They do know your needs and will do what they can to help. They know if I'm unwell.” from the report
People were at risk of harm
seriousRisks were not reliably assessed or monitored. Inspectors found problems involving fire safety, infection control, pressure care, food and fluid intake.
“Risks were not always identified, monitored or mitigated. This potentially placed people at risk of harm.” from the report
Safeguarding failures
seriousThe provider did not properly respond to allegations or report safeguarding concerns externally. Inspectors made safeguarding alerts to the local authority.
“The provider failed to protect people from abuse or improper treatment. They did not ensure safeguarding concerns were reported externally.” from the report
Unsafe staffing and recruitment
seriousAfternoon and evening staffing was not based on people's needs, and staff said they struggled to provide care. Recruitment records did not fully check applicants' employment history or previous care work.
“The provider did not ensure there were sufficient numbers of staff who were suitably qualified, competent, skilled and experienced.” from the report
Training and supervision gaps
needs fixingThe home could not clearly show what training staff had completed. New staff did not have their competence assessed, and staff did not receive timely supervision.
“The competency of new staff was not assessed to ensure they were safe and knowledgeable in their practice.” from the report
Consent and mental capacity records
seriousCare plans for people living with dementia did not include required mental capacity assessments or best-interest decisions. Consent to care was not routinely recorded.
“This left people at risk of unlawful restraint and deprivation of their rights, and of not receiving care which might have been in their best interests.” from the report
Complaints were not properly handled
needs fixingRepeated complaints about missing laundry were not recorded in the complaints file, and there was no clear record of actions taken. Staff concerns about staffing were also not logged.
“The complaints process was not effective to ensure a meaningful response to complaints.” from the report
- 01What immediate changes have been made to fire safety, including staff fire training, emergency light checks and the fire risk assessment?
- 02How are staffing levels now assessed in the afternoons and evenings against the care and emotional needs of each person?
- 03How are safeguarding concerns recorded, reported and followed up, and who checks that this happens?
- 04How are food and fluid intake, repositioning and pressure care now recorded and reviewed each day?
- 05What new system records complaints, including missing laundry, and shows the action taken and the outcome?
This began as a focused inspection and was expanded to a comprehensive inspection covering all five key questions, the premises, care provided and infection prevention and control. This explanation was written from the published report of 20 July 2023 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Teignbridge House Care Home Limited
6 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
Read what inspectors found at Teignbridge House Care Home Limited →
- July 2023Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
Read what inspectors found at Teignbridge House Care Home Limited →
- November 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 January 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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Most charge £1,020 to £1,270 a week. 15 can care for a couple. 13 years' experience on average.
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