CQC report explained · a nursing home
What the CQC found at Ticehurst Care Home With Nursing
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found comprehensive risk assessments, enough suitable staff, safe recruitment and systems for administering and checking medicines. The home also had infection-control measures and reviewed incidents for lessons.
- Effective?
- Good
- Care plans reflected people's needs and preferences, and staff had relevant training. People were supported with food, healthcare, rehabilitation and decisions about their care.
- Caring?
- Good
- Inspectors saw kind and respectful interactions. People were involved in decisions, and staff promoted privacy, dignity, independence and individual preferences.
- Responsive?
- Good
- Care plans were detailed and personalised. The home offered activities, communication support, religious support, complaint handling and end-of-life care suited to people's needs.
- Well-led?
- Good
- Inspectors found an open and positive culture, regular quality checks and a service improvement plan. The management team sought feedback from people, relatives and staff and worked with other agencies.
What inspectors found, September 2019
Ticehurst Care Home With Nursing was rated Good; inspectors found safe, kind and personalised care, with lessons learned from past incidents.
This was an unannounced planned inspection on 22 and 27 August 2019. Inspectors spoke with people living in the home, relatives, staff and other professionals. They reviewed care records, staff records, medicines records and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found suitable staffing, safe medicines systems, detailed care plans and respectful relationships between staff and people.
The home had acted on lessons from incidents, including a medicines error and an incident that showed pre-admission assessments needed more detail. The overall rating and all five area ratings remained Good, as they were at the previous inspection published in February 2017.
Safe medicines practice
Staff followed medicines procedures, had their competence checked and used audits to identify gaps or mistakes. Inspectors found no gaps in the records reviewed.
“We noted there were no gaps in records.” from the report
Kind and respectful care
People and relatives described staff as kind and caring. Inspectors observed warm interactions and saw staff protecting people's privacy and dignity.
“We observed staff and management being very kind, caring and warm with the people they were supporting.” from the report
Personalised support
Care plans contained detailed information about people's needs, preferences and how they wanted to receive care. People were involved in decisions about their support.
“People's needs were captured in comprehensive care plans which contained detailed information about how people wished to receive their care and support.” from the report
Activities and relationships
The home offered group and one-to-one activities, trips and events. It also supported people to maintain cultural, religious and personal interests.
“One to one activities were available for people unable or choosing not to join in.” from the report
Open management
Inspectors found a warm, friendly culture with systems for quality checks, feedback and improvement. Relatives and staff had opportunities to share their views.
“There was a warm and friendly culture within the service with a clear drive to provide high quality care.” from the report
Pre-admission assessments
needs fixingThe provider identified that pre-admission assessments needed to be more detailed after an incident involving a new resident. Families should ask how this improvement is now applied.
“The provider also identified improvements were needed in their pre-admission assessments following an incident occurring with a new resident.” from the report
Previous medicines error
needs fixingThe report records a medicines error. Staff were given refresher training afterwards, so families may wish to ask what safeguards are now in place.
“We noted that following a medicines error staff were sent on refresher training.” from the report
- 01How have you made pre-admission assessments more detailed since the incident mentioned in the report?
- 02What safeguards are now in place following the medicines error, and how are medicines records checked?
- 03How would you support my relative's individual interests, cultural or religious needs and communication needs?
- 04What activities and one-to-one support would be available if my relative did not want to join group activities?
- 05How would my family be involved in care reviews and end-of-life decisions if needed?
This was an unannounced planned inspection covering all five CQC questions, the premises and the care provided; all ratings were reviewed and remained Good from the previous inspection. This explanation was written from the published report of 25 September 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.
What inspectors found, February 2017
Rated Good; inspectors found safe, kind and personalised care, with some care records needing improvement.
This was an unannounced inspection on 11 and 12 January 2017. Inspectors spoke with people living in the home, relatives, staff and health professionals. They also observed care and checked care records, staff records and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines arrangements, suitable training and good access to health care. People were treated with kindness and respect, and their care was planned around their individual needs.
There were some record-keeping issues. Staff had not always fully recorded why certain decisions had been made for people who lacked capacity. A few care plan inconsistencies were still being corrected. One emergency evacuation plan was brought up to date during the inspection.
Safe medicines and staffing
Medicines were ordered, stored, given and recorded safely. Inspectors also found enough staff to respond to people’s needs without rushing them.
“People were supported to take their medicines safely. Suitable arrangements were in place for ordering, storing, administering and disposing of medicines” from the report
Kind and dignified care
Staff used a calm, patient and respectful approach. They protected privacy and supported people to keep important relationships.
“Staff had created a positive, relaxed environment that suited the people living at the home.” from the report
Personalised support
Care plans included people’s routines, preferences and health needs. Staff showed inspectors that they understood how individuals wanted to be supported.
“The care plans were centred on the needs of each person and took account of their medical history, their preferred daily routine and how people wished to receive care and treatment.” from the report
Strong management and improvement
Managers were described as approachable and supportive. The home used audits, feedback and action plans to identify and make improvements.
“An appropriate quality assurance system was in place that focused on continuous improvement.” from the report
Mental capacity records
needs fixingStaff had not always used the provider’s full form to record decisions made for people who lacked capacity. Most records were updated during the inspection, but families should check that these records remain complete.
“However, staff had not always used the provider's two part form to document the process they had followed.” from the report
Care plan inconsistencies
minorThe home had moved to a new care plan format. Most plans were good, but a few inconsistencies were still being corrected.
“Whilst there were still a few inconsistencies that staff were working through, most care plans were well organised” from the report
- 01How do you make sure mental capacity decisions, including decisions about bed rails and medicines, are fully recorded and reviewed?
- 02How do you check that information in the new care plans is complete and consistent?
- 03How would you support my relative if their dementia or other needs became more complex?
- 04How do you decide whether the staffing level and mix are still suitable for each person’s needs?
- 05How do you make sure personal emergency evacuation plans remain up to date?
This was an unannounced inspection covering all five CQC areas and providing an overall rating; the report also says the previous inspection in February 2015 found no breaches. This explanation was written from the published report of 17 February 2017 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 Ticehurst Care Home With Nursing
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- September 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Ticehurst Care Home With Nursing →
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Ticehurst Care Home With Nursing →
- June 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 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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