CQC report explained · a residential care home
What the CQC found at Tillson House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks were assessed and reviewed, staff had safeguarding and moving and handling training, and there were enough experienced staff to meet people's needs. Medicines, recruitment and infection control were also found to be safe.
- Effective?
- Requires improvement
- This area was not inspected during this focused visit. The previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. The previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. The previous rating was used when calculating the overall rating.
- Well-led?
- Good
- The management team had effective audits, action plans and staff support systems. People and relatives were involved in decisions, although people were not always encouraged to have meaningful interactions.
What inspectors found, November 2021
Tillson House rated Good; inspectors found safe, well-managed care, but people did not always have meaningful interaction.
This was an unannounced focused inspection on 28 October 2021. Inspectors looked at whether the home was safe and well-led. They spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
Inspectors found that risks were managed safely, staffing was sufficient, medicines were handled correctly and infection control arrangements were effective. Care records included people's preferences and risks. The provider had improved its checks and acted when problems were found.
The home was rated Good overall, with Safe and Well-led also rated Good. This was an improvement from the previous rating of Requires Improvement. The other three areas were not inspected during this visit, so their earlier ratings were used in the overall rating.
Managing risks
Care plans and risk assessments contained personalised guidance and were reviewed regularly. Staff understood how to support people safely, including when using hoisting equipment.
“Risk was managed effectively and people's safety was monitored and managed.” from the report
Safe medicines
Medicine records were completed accurately. Staff had appropriate training, and checks were carried out regularly.
“Medicines were managed safely. We saw medicine administration record (MAR) charts were in place and had been completed accurately, showing people had received their medicines as prescribed.” from the report
Improved management
The provider had strengthened its audits and used action plans when issues were identified. Staff said managers were supportive and approachable.
“When issues were identified, effective action plans with clearly set ownership and timescales were developed to drive improvement within the service.” from the report
Personalised records
Care records included people's needs, preferences, routines, interests and family relationships. People and relatives were involved in reviewing care plans.
“Information within care plans and risk assessments was person-centred and included relevant information around people's needs, their likes and dislikes, their life history and family relationships.” from the report
Limited meaningful interaction
needs fixingInspectors saw people in lounges and bedrooms with little or no interaction beyond care tasks. The manager said the home was waiting for a new activities co-ordinator and would support staff to provide more interaction.
“Throughout our inspection we saw people sat in lounges and bedrooms who had little to no interaction with staff or other people other than when staff were completing care tasks.” from the report
Some family concerns about staffing
minorSome relatives raised minor concerns about staffing levels. Inspectors found there were enough experienced and qualified staff to meet people's needs safely.
“Whilst some relatives raised minor concerns around staffing levels, we found there were enough experienced and qualified staff deployed to safely meet people's needs.” from the report
- 01What activities and one-to-one interaction are now available for people who spend time in their rooms or lounges?
- 02How do you check that people are having meaningful conversations and social contact, rather than only receiving care tasks?
- 03What is the current staffing level on each shift, and how do you respond if staffing falls below plan?
- 04Has the manager's application to register with the CQC been completed?
- 05What progress has been made with the refurbishment plan mentioned in the report?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 13 November 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, October 2021
Overall rating Requires Improvement; Safe was Inadequate because hoisting was unsafe, and Well-led Requires Improvement.
This was an unannounced focused inspection on 8 April 2021. Two inspectors and an expert by experience spoke with people, relatives and staff. They reviewed care records, medicines records, audits, policies and infection control records.
Inspectors found serious problems with hoisting. One person had been seriously injured, and staff used the wrong sling and did not have the right risk assessment. Other hoisting practices were also unsafe. This led to a breach of Regulation 12.
Staffing had improved and staff were described as kind and caring. However, checks by managers had not found problems with risk assessments, medicines records or privacy in the building. Safe fell from Requires Improvement to Inadequate. Well-led remained Requires Improvement, and the overall rating remained Requires Improvement.
Improved staffing
Staffing levels had improved since the previous comprehensive inspection. Inspectors found that staff provided help promptly when people needed it.
“At this inspection staffing levels had improved. If people needed assistance staff provided this promptly.” from the report
Kind staff
People and relatives gave positive feedback about staff being friendly, kind and caring.
“The staff were kind and caring and relatives made many positive comments about them.” from the report
Activities and involvement
People were offered activities such as music, games, crafts and gardening. People and staff could share their views, and managers acted on suggestions.
“People were encouraged to take part in activities to increase their well-being.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including use of protective equipment and testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Unsafe hoisting
seriousHoisting was not consistently safe. One person was seriously injured, the wrong sling was used, and staff did not always explain what they were doing.
“People were not always safe when being hoisted. A person had been injured and we observed poor hoisting practice.” from the report
Incomplete risk assessments
seriousSome risk assessments did not give staff enough personalised information to move people safely. This was part of the breach of Regulation 12.
“The provider had not ensured risks in relation to people's care were properly managed to prevent avoidable harm.” from the report
Weak management checks
needs fixingAudits had not identified problems with risk assessments, medicines records or the environment. The CQC recommended that the audit system be improved.
“It is recommended that the service's audit system is reviewed and improved to ensure it is effective in identifying shortfalls in the service.” from the report
Privacy in bathrooms
needs fixingThree upstairs bathroom doors had gaps that allowed people inside to be seen. Managers said seals would be fitted.
“Premises audits had failed to identify that three upstairs bathroom doors had gaps around them, so it was possible to see inside.” from the report
Undated medicines protocols
minorSome protocols for medicines taken only when needed were undated. The manager said these had been reviewed and dated after the inspection.
“However, some 'as required' medicines protocols were undated.” from the report
- 01What changes have been made to hoisting risk assessments since the inspection, and are they personalised for my relative?
- 02Have all staff who may hoist residents been retrained and had their practical competence checked?
- 03How do managers now check that staff follow the correct sling and moving and handling instructions?
- 04Have the bathroom door gaps been repaired, and how is residents' privacy checked now?
- 05How are medicines protocols checked to make sure they are dated and current?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 29 October 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.
Every inspection of Tillson House
5 rated inspections over 6 years: the service has held its Good rating throughout.
- November 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2021Requires improvementSafe: InadequateWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- February 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- September 2012
Registered with the Care Quality Commission on 28 September 2012.
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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