CQC report explained · a nursing home
What the CQC found at Tilford Care & Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2022
Rated Requires Improvement; inspectors found infection control and management oversight were not always safe or effective.
This was an unannounced focused inspection on 11 November 2021. Two inspectors spoke with people, relatives and staff, observed care, and checked care, medicine, staffing and management records.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Inspectors saw staff not consistently wearing face masks correctly and found some personal protective equipment stored in a bathroom, which increased the risk of infection spreading.
Inspectors also found that management checks had not identified these problems. Some staff said they did not always have enough time or support to read care plans and risk assessments. The provider took some action during and after the inspection, including moving the PPE and creating a better staff room.
There were also positive findings. People and relatives said they felt safe and that staff were kind. Inspectors found enough staff at the inspection, safe medicine systems, care plans for known risks, and arrangements for emergencies.
People felt safe
People and relatives told inspectors they felt safe. Staff had safeguarding training and understood what to do if they suspected abuse.
“People told us they felt safe with staff.” from the report
Safe medicines
Inspectors found medicines were recorded, stored and administered safely. Staff had regular training and competency checks.
“People's medicines were managed in a safe way.” from the report
Risk planning
Care records identified known risks and gave staff guidance. Emergency evacuation plans were also in place.
“Care records were in place to identify and manage risks.” from the report
Masks and PPE
seriousStaff did not consistently wear face masks correctly in communal areas. PPE was also stored in a bathroom, creating a risk of cross-contamination.
“Failure to consistently adhere to national guidance in relation to the use and storage of personal protective equipment placed people at increased risk of contracting COVID-19.” from the report
Weak management checks
seriousProvider audits had not found the PPE and staff room problems. Inspectors said shortfalls were not always identified or acted on.
“Failure to ensure there were effective governance systems in place to assess and monitor the quality of the service meant that shortfalls were not always identified and acted on.” from the report
Access to care plans
needs fixingSome staff said they did not always have time or support to read care plans and risk assessments. This created a risk that staff might not know people's current needs.
“This meant there was a risk staff may not always have been fully aware of people's up-to-date health, social and care needs where this was recorded in care plans.” from the report
Staff feedback was not always acted on
needs fixingStaff could give feedback through surveys and meetings, but inspectors found action was not always taken in response.
“We reviewed minutes of staff meetings and staff told us they were able to feedback using surveys, however we saw that action was not always taken in response to surveys.” from the report
- 01How do you now check that all staff wear masks correctly in communal areas?
- 02Where is PPE stored now, and how do you check that its storage cannot cause cross-contamination?
- 03How are staff given protected time to read each person's care plan and risk assessments?
- 04What changes have been made to management audits since the inspection?
- 05How do you record and act on concerns raised through staff surveys?
This was a focused inspection of Safe and Well-led only; the other key question ratings were not inspected and were carried over from previous comprehensive inspections. This explanation was written from the published report of 19 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, August 2020
Tilford Care & Nursing Home was rated Good; inspectors found safe, kind care and better leadership, but records were not always detailed.
This was a focused inspection on 15 July 2020. Inspectors looked at safety, care, dignity and management after concerns about alleged abuse, infection control and cleanliness. They spoke with people, staff and relatives, checked the home and reviewed care and management records.
Inspectors found people were protected from abuse and avoidable harm. The home was clean and tidy, medicines were managed safely, and there were enough staff. People appeared comfortable with staff and were treated kindly, with their privacy and choices respected.
The home had improved since its previous Requires Improvement rating, published in December 2019. The overall rating changed to Good. Safe, Caring and Well-led were inspected, but the report says these areas were inspected but not rated. Effective and Responsive were not covered by this inspection.
Protection from abuse
The home had improved its safeguarding process. Staff understood how to report concerns, and previous concerns had been investigated.
“People were appropriately protected from the risk of abuse.” from the report
Kind relationships
People appeared relaxed with staff and inspectors saw warm, supportive interactions. Staff knew people's personal needs, interests and preferences.
“We observed kind and caring interactions throughout our inspection.” from the report
Clean surroundings
Communal areas and bedrooms were clean and tidy. Extra cleaning checks had been introduced, and identified issues were dealt with the same day.
“We observed people's rooms to be clean and tidy and free from any bad odours.” from the report
Improved leadership
Staff and professionals described a better culture under the current management. Leaders were open about areas still needing improvement and were taking action.
“Staff and healthcare professionals told us the culture within the service had improved since the registered manager had been in place.” from the report
Face mask use
needs fixingOn several occasions, inspectors saw masks worn under the chin or with the nose uncovered. Management reminded staff and planned to seek further training.
“However, on a few occasions we had to raise with the registered manager that some facemasks were being worn either under the chin or pulled down, so the nose was exposed.” from the report
Daily records
needs fixingDaily notes did not always contain enough personalised detail about what people had done or discussed. Managers knew about this and were supporting staff to improve.
“Daily notes for people were inconsistent in their detail and quality.” from the report
New checks not yet established
minorSome new quality checks had only recently started. Inspectors said they needed more time to become consistent across the home.
“This system will need time to be embedded across the home and we will check on the progress at the next comprehensive inspection.” from the report
- 01How do you now check that daily notes contain personalised and detailed information about each person?
- 02What extra training or checks have been introduced to make sure staff wear face masks correctly?
- 03How have the new audits of care plans, incidents, accidents and health and safety been embedded?
- 04How do people and relatives currently give feedback, and what changes have been made in response?
- 05What were the outcomes of the next comprehensive inspection mentioned in this report?
This was a focused inspection covering Safe, Caring and Well-led; Effective and Responsive were not covered, and the three inspected areas were marked as inspected but not rated. This explanation was written from the published report of 14 August 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 Tilford Care & Nursing Home
4 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- January 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- October 2019Requires improvementdown from GoodSafe: GoodCaring: GoodWell-led: Requires improvement
- January 2018GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016
Registered with the Care Quality Commission on 20 December 2016.
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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