CQC report explained · a residential care home
What the CQC found at Tilsley House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Rated Requires Improvement; inspectors found kind care and enough staff, but concerns about safety, care records, medicines and management checks.
This was an unannounced focused inspection on 07 and 11 November 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care records and management documents.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also rated Requires Improvement. Inspectors found unclear risk assessments, unsafe medicines practices, incomplete care records, weak checks on food and fluid intake, and quality systems that had not identified important problems.
There were also positive findings. Staffing levels were sufficient, people described the home as safe, and staff were seen being kind and respectful. People were supported to make choices and staff asked for consent. The home had been rated Good at the previous inspection, published on 21 July 2021.
Enough staff
Inspectors found staffing levels were sufficient to keep people safe. People and relatives also said staff came quickly when help was needed.
“There were enough staff to keep people safe.” from the report
Kind interactions
People and relatives said people were safe, and inspectors observed respectful care between staff and people.
“We observed kind and respectful interactions between staff and people.” from the report
Choice and consent
Staff asked people for consent before providing support. The home was working within the principles of the Mental Capacity Act.
“Staff understood the need to ask people's consent before supporting them.” from the report
Access to healthcare
People had ongoing access to healthcare, with staff able to seek advice and support when needed.
“People had access to ongoing healthcare.” from the report
Unclear risk assessments
seriousRisk assessments did not always explain how staff should keep people safe. Inspectors found examples involving hoist use, walking support and skin checks.
“Risk assessments were not clear and accurate meaning staff did not have effective guidance about how to keep people safe.” from the report
Medicines management
seriousMedicine records were not always completed accurately. Medicines were not always stored or disposed of safely, and there were gaps in the controlled medicine records.
“Medicines were not always stored and disposed of in line with best practice.” from the report
Care plans and records
seriousCare plans were not always current or detailed enough, and some staff had not read them. This meant inspectors could not be assured that care matched people's needs.
“Care was not always tailored to people's needs.” from the report
Food and fluid monitoring
needs fixingFood and fluid records did not always show that people had enough to eat and drink. Staff did not always provide specialist equipment needed during meals.
“Food and fluid records did not show that people had been supported to have enough to eat and drink.” from the report
Weak quality checks
seriousThe provider's checks had not found several problems, including concerns about medicines, recruitment, capacity assessments and nutrition. Electronic care-record warnings had also not been acted on.
“The systems to check the quality of care delivery were not effective to drive improvements.” from the report
Recruitment checks
needs fixingThree staff files did not contain a recorded DBS check. Inspectors recommended that the provider get support to improve recruitment practices.
“Staff recruitment processes were not robust.” from the report
- 01What changes have you made to risk assessments for hoists, walking support and skin checks?
- 02How do you now check that medicines are recorded, stored and disposed of safely?
- 03How do you make sure care plans are up to date and that all staff have read them?
- 04How do you check that people at risk of malnutrition receive enough food, fluids and the correct eating equipment?
- 05What evidence can you show that your quality checks now identify and fix problems promptly?
This was an unannounced focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 15 April 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.
What inspectors found, July 2021
Tilsley House Care Home rated Good; inspectors found safe, kind and well-led care, and the previous safe-care breach had been corrected.
This was an unannounced, focused inspection on 21 June 2021. One inspector visited, an assistant inspector contacted relatives, and the team reviewed care records, medicines records, staff files and management records. They also checked infection prevention and control.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found that people were protected from avoidable harm, there were enough staff, medicines were managed safely, and infection control measures were in place.
The inspection followed a previous Requires Improvement rating and a breach involving safe care and treatment. Inspectors found that enough improvement had been made and that the home was no longer in breach of that regulation. The other areas were not assessed during this visit, so their previous ratings were carried forward.
Risks were managed
Risk assessments had been improved, including clearer guidance about mobility and people's independence. Changes to radiators and the laundry room reduced identified risks.
“People received safe care and were protected from the risk of avoidable harm.” from the report
Medicines were handled safely
Medicines were stored and given according to instructions. Records and guidance for as-required medicines and topical creams were also checked.
“People received their medicines in line with the prescriber's instructions.” from the report
Enough staff
People and relatives said there were enough staff. Inspectors also found that recruitment checks had been completed safely.
“There are enough staff to look after me,” from the report
Strong management oversight
The home used audits and other checks to find errors, omissions and patterns such as falls. Staff, people and relatives spoke positively about the management.
“Governance systems were used effectively to identify concerns, errors and omissions.” from the report
Person-centred care
Inspectors observed staff adapting how they spoke with and supported different people. People and relatives described good care and outcomes.
“Staff spoke about and treated people in a person-centred way.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you now check that risk assessments remain accurate when a person's mobility or needs change?
- 02How do you monitor fluid intake and respond if records show that someone may be at risk of dehydration?
- 03How do you make sure there are enough trained staff on every shift without relying on agency staff?
- 04How are medicines, as-required medicines and topical creams checked for accuracy and safe administration?
- 05What evidence can you show about the areas not assessed in this inspection, especially Effective, Caring and Responsive?
This was a focused inspection of Safe and Well-led, including infection control; the other key-question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 15 July 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 Tilsley House Care Home
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- April 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- September 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 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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23 live-in carers within about an hour of North Somerset
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.
Most charge £1,050 to £1,320 a week. 19 can care for a couple. 12 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.