CQC report explained · a residential care home
What the CQC found at Tennyson Wharf
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found systems to manage risks, protect people from abuse and control infection. They identified inconsistent records for as-needed medicines and some falls, but the home said these were addressed immediately.
- Effective?
- Good
- This question was not inspected during this targeted visit. A previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this targeted visit. A previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this targeted visit. A previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Frequent changes of manager affected staff morale, consistency and the ability to sustain improvements. Staff and relatives also reported problems with support and communication.
What inspectors found, March 2021
Rated Good overall, but well-led was Requires Improvement because leadership and communication were inconsistent.
This was an unannounced targeted inspection on 27 January 2021. Inspectors focused on infection prevention and control, and risks linked to falls from moving and handling equipment. They spoke with people, relatives and staff, and reviewed care, medicine, staffing and management records.
The home was clean and inspectors were assured that infection control measures were effective. Risk assessments were in place for issues such as falls, choking and skin damage. Staff followed good practice when giving medicines, although some records for medicines taken when needed were unclear. Some falls were also not recorded consistently.
The main weakness was leadership. There had been frequent changes of registered manager, and staff and relatives reported poor support and communication. The overall rating remained Good, but the well-led rating remained Requires Improvement. The report says the provider took immediate steps to address the issues raised.
Infection control
Inspectors found the home visibly clean. Staff used protective equipment correctly, followed cleaning schedules and had infection control training.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Managing risks
Risk assessments for falls, choking and skin damage were in place and up to date. Fire and environmental safety checks were also carried out.
“Risk assessments were in place to reduce risks associated with choking, falls and skin breakdown.” from the report
Medicine practice
Staff were observed giving medicines safely and explaining them to people. The home had also introduced a better system for reporting medicine errors.
“Staff were observed following good practice when administering people's medicines.” from the report
Quality monitoring
The provider and senior managers had access to audits and action plans. This gave them oversight of improvements during the pandemic.
“Senior managers had access to the audit reports throughout the pandemic and had clear oversight of the actions and progress of the service.” from the report
Leadership changes
needs fixingThere had been a high turnover of managers. Staff said this disrupted the team and affected morale, while inspectors said it risked improvements not lasting.
“Frequent changes of registered manager reduced the providers ability to achieve and maintain improvements.” from the report
Communication and staff support
needs fixingRelatives said they did not always receive timely information about illness or hospital admissions. Most staff said they did not feel supported or valued by the registered manager.
“Most staff told us they did not feel supported or valued by the registered manager.” from the report
Staffing concerns
needs fixingStaff and relatives were concerned that low staffing levels affected the quality of care. Senior managers said staffing would be kept under constant review.
“Staff and relatives, we spoke with consistently told us they were concerned low staff levels were having an impact on the quality of care people received.” from the report
Incomplete records
needs fixingRecords for medicines taken when needed did not always show clearly what had been given or whether it had worked. Some falls were also missing from falls logs.
“Medicines people took on an 'as needed' basis had not always been recorded clearly or consistently.” from the report
- 01What staffing levels are in place now, and how do you respond when staffing is low?
- 02What has changed to improve communication with relatives about illness, hospital admissions and changes in management?
- 03How are records for as-needed medicines checked to show whether they were effective?
- 04How do you make sure every fall is recorded and reviewed?
- 05What has changed to improve staff support and make leadership more consistent?
This was a targeted inspection of infection control and specific falls-related risks, with Safe and Well-led assessed; the other key-question ratings were carried over from previous comprehensive inspections. This explanation was written from the published report of 2 March 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, January 2020
Rated Good overall; inspectors found safe, kind and responsive care, but the home’s leadership was still rated Requires Improvement.
Inspectors visited the home without notice on 11 and 12 November 2019. They spoke with six people living there, two relatives and ten staff. They also checked care records, medicines records, staff files and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found that people were protected from abuse, medicines were managed safely, staff were trained, and people received kind and person-centred care. Food, activities and access to health professionals were also viewed positively.
Well-led was rated Requires Improvement. A new manager had made important changes and the home was meeting the regulations, but inspectors wanted to see a longer period of consistent good practice. Some care plans still needed more information about people's life histories, likes and dislikes.
The overall rating improved from Requires Improvement at the previous inspection in May 2019. The previous breaches had been addressed, and the home was no longer in breach of regulations at this inspection.
Safe medicines management
Medicines records were accurate and clear. Staff who administered medicines received training and competency checks.
“People's medicines were administered safely. Records of administration were accurate and documented clearly.” from the report
Kind and respectful staff
People and relatives described staff as kind. Inspectors observed staff supporting privacy, dignity and independence.
“People and relatives consistently confirmed staff were kind and treated them well.” from the report
Activities and social life
People were offered activities, outings and opportunities to try new things. Inspectors saw people joining in with music and games.
“The session was uplifting and positive, people were laughing and smiling throughout.” from the report
Clean environment
The home was clean and infection control checks were carried out regularly.
“The standard of cleanliness throughout the home was of a high standard.” from the report
Care plans lacked some personal detail
needs fixingSome care plans did not contain enough information about people's life histories, likes and dislikes. The manager said work was already planned to improve this.
“Some care plans lacked the detail around people's life histories and what people liked and disliked.” from the report
Some delays in staff response
needs fixingAlthough staffing levels were judged sufficient overall, some people said they sometimes waited longer than they should. Staff also said sickness could make staffing difficult.
“Some people said they thought staff met their needs promptly, but some thought they had to wait longer than they should do.” from the report
Leadership needed a longer track record
needs fixingThe new manager had made improvements, but inspectors did not yet consider the changes fully established over time.
“To improve the rating to Good would require a longer-term track record of consistent good practice.” from the report
- 01How have you continued to improve care plans so they include each person's life history, likes and dislikes?
- 02How quickly do staff respond to call buzzers, particularly at weekends or when there is staff sickness?
- 03What evidence can you show of consistent good leadership since the inspection?
- 04How are choking risk assessments checked to make sure the food guidance is accurate and consistent?
- 05What activities are now available for people living with dementia?
This was an unannounced planned inspection covering all five key questions, with the overall rating based on findings from the home, its care and its management. This explanation was written from the published report of 28 January 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 Tennyson Wharf
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- March 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2020Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- May 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- March 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- February 2015
Registered with the Care Quality Commission on 11 February 2015.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
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