CQC report explained · a nursing home
What the CQC found at Tollesby Hall Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found safe care and kind staff, but gaps in personal care records and quality checks.
The inspection took place on 16 and 20 February and 15 March 2023. Inspectors spoke with people, relatives and staff, and checked care, medicines and management records.
The home was rated Good for Safe. Inspectors found safe recruitment, suitable medicines systems, infection control and safeguarding arrangements. People’s risks were assessed and accidents were reviewed.
The home was rated Requires Improvement for Caring and Well-led. People did not always receive personal care in line with their choices, and records about personal care, fluids and safety checks were incomplete. CCTV controls were also not effective.
The overall rating changed from Good at the last inspection to Requires Improvement. The inspection was focused on Safe, Caring and Well-led, so the other key questions were not inspected.
Safe medicines
Medicines were managed safely. Staff were trained and medicines audits were effective.
“Medicines were managed safely. Competent trained staff followed guidance for the management, storage, administration, and disposal of medicines.” from the report
Infection control
Inspectors were assured that the home had suitable infection prevention measures and used protective equipment safely.
“We were assured that the provider was using PPE effectively and safely.” from the report
Kind staff interactions
Although care was not always consistent, inspectors saw staff speaking respectfully and supporting people's privacy.
“Staff interaction was kind and caring. We observed staff speaking with people respectfully.” from the report
End-of-life care
The home had a recognised end-of-life care accreditation and healthcare professionals gave positive feedback about this care.
“The home was passionate about providing quality end of life care.” from the report
Personal care choices
needs fixingPeople were not always supported in line with their choices. Inspectors found records showing that one person had only been offered a bath or shower within a 20-day period.
“People were not always supported in line with their choices.” from the report
Incomplete care records
seriousRecords about personal care, fluid intake, thickener and safety checks were not always complete. The home had started improvements, but problems were still found during the inspection.
“Records relating to people's support with personal care, fluid intake, and safety checks were not always complete.” from the report
CCTV controls
needs fixingWarning signs were missing and equipment showing CCTV images was not always secure. The provider's annual review had not identified these issues.
“CCTV control measures were not effective. Appropriate signage warning of the use of recording equipment were not present, and equipment displaying the images was not always secured.” from the report
Waiting for support
needs fixingPeople gave mixed feedback about how quickly staff responded. Some people said they had to wait for help.
“Some people told us staff were present when required whilst others told us they had to wait.” from the report
- 01How do you now make sure every person's bathing, showering and other personal care choices are offered and recorded?
- 02What checks are now in place to make sure care records, fluid records and safety checks are complete and accurate?
- 03What changes have been made to CCTV warning signs, equipment security and the annual review process?
- 04How do you review staffing levels and respond when people say they are waiting too long for help?
- 05What action plan did you send to CQC, and what improvements have been completed since this inspection?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their previous ratings were carried over when calculating the overall rating. This explanation was written from the published report of 20 June 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, November 2020
Inspected but not rated; inspectors found good infection control, with visitor screening identified for further development.
This was an announced, targeted inspection on 29 October 2020. It looked only at infection prevention and control because the home had been identified as a designated care setting for people discharged from hospital with Covid-19.
Inspectors found systems to reduce the spread of infection. These included safe visiting arrangements, social distancing, safe use of protective equipment, Covid-19 testing, safe admissions and plans for managing an outbreak.
The home was not given an overall quality rating. Safe was recorded as inspected but not rated. The inspectors said they were assured about infection control, but they signposted the home to resources to improve visitor screening.
Infection control
The home had systems to reduce the risk of visitors catching or spreading infections.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Protective equipment
Staff used protective equipment safely, and supplies were available around the building.
“Staff used and disposed of personal protective equipment (PPE) safely. Sufficient stocks of PPE were in place and conveniently positioned around the building.” from the report
Safe admissions
The home had clear arrangements for admitting people safely.
“Clear systems were in place to admit people safely to the service.” from the report
Testing and outbreak planning
Testing was taking place for residents and staff, and the home had arrangements to prevent or manage outbreaks.
“We were assured that the provider was accessing testing for people using the service and staff.” from the report
Social distancing
Staff promoted social distancing and had systems to help keep people safe during an outbreak.
“Staff promoted and practised social distancing. Systems were in place to keep people safe should an infection outbreak occur.” from the report
Visitor screening
minorInspectors signposted the home to resources to improve how visitors were screened when entering the building.
“We have also signposted the provider to resources to develop their approach to screening visitors entering the building.” from the report
- 01What changes have you made to visitor screening since inspectors signposted you to further resources?
- 02How do you check that visitors follow infection prevention and social distancing rules?
- 03How often are residents and staff tested, and how are the results acted on?
- 04What happens when someone is admitted to the home from hospital with a positive Covid-19 status?
- 05How would you manage an infection outbreak in the home?
This was a targeted inspection of infection prevention and control only; it did not provide an overall quality rating or assess the other key questions. This explanation was written from the published report of 4 November 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 Tollesby Hall Nursing Home
2 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingSafe: GoodEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- November 2020Inspected but not ratedSafe: Inspected but not rated
- December 2017GoodSafe: GoodCaring: OutstandingWell-led: Good
- July 2016
Registered with the Care Quality Commission on 18 July 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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35 live-in carers within about an hour of Middlesbrough
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 £980 to £1,230 a week. 31 can care for a couple. 9 years' experience on average.
“I found Alison to be kind , caring helpful concencious... Alison has a heart of gold”
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
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