CQC report explained · a residential care home
What the CQC found at Tolson Grange
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2021
Tolson Grange was inspected but not rated; inspectors found good infection prevention and control arrangements.
This was a targeted, announced inspection on 27 May 2021. It checked infection prevention and control because of coronavirus outbreaks in care homes.
Inspectors found that staff used protective equipment, visitors were checked and tested, and the home was clean and well ventilated. Staff and residents took part in COVID-19 testing.
The home had infection control audits and up-to-date guidance for staff. Inspectors were assured that infection risks were being managed safely.
The home was inspected but not rated. This was not a full inspection of all areas of care.
Protective equipment
Staff wore protective equipment throughout the home. They had training and understood their infection control responsibilities.
“Staff wore PPE throughout the building. Designated areas were available for staff to change into their uniform which helped reduce the risk of spreading infection.” from the report
Visitor safety
The home had several checks for visitors, including COVID-19 testing, protective equipment, questionnaires, temperature checks and hand sanitising.
“A robust system was in place for managing visitors to the home. This included testing for COVID-19 on arrival, wearing appropriate PPE, completing questionnaires, checking temperatures and hand sanitising.” from the report
Clean surroundings
Inspectors found the premises clean, hygienic and well ventilated. Frequently touched surfaces were cleaned regularly.
“The premises were clean, hygienic and well ventilated. There were regular cleaning regimes in place, including cleaning frequently touched areas such as light switches, door handles and hand rails.” from the report
Testing and monitoring
Staff and residents took part in the government COVID-19 testing scheme. The home also completed infection control audits.
“Staff engaged with the government COVID-19 testing scheme for people living in the home and staff.” from the report
Inspectors raised no specific concerns in this report.
- 01Have the infection prevention and control arrangements described in the report been maintained since the inspection on 27 May 2021?
- 02How are visitors currently tested, screened and supported to use protective equipment?
- 03How often are frequently touched areas cleaned and how are these checks recorded?
- 04How are residents and staff currently tested for infections?
- 05When was the home's last full inspection covering care, staffing, medicines and management?
This was a targeted inspection of infection prevention and control practices only; the service was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 23 June 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, February 2018
Tolson Grange was rated Good; inspectors found safe, kind and responsive care, with a few records and management issues to follow up.
This was an unannounced inspection over two visits. Inspectors spoke with people living in the home, relatives, staff and health professionals. They observed care and checked care plans, medicines records and management documents.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People were supported by enough trained staff, received kind care, and had their choices, privacy and dignity respected.
Care plans reflected people's needs and preferences and were reviewed when needs changed. Inspectors also found safe medicines arrangements, good food and drink support, access to healthcare, activities and systems for handling complaints.
The home was rated Good at the previous inspection and remained Good. Inspectors recommended clearer recording of staff supervision. They also found that guidance for two people's covert medicines needed improving, but the provider confirmed this was added after the inspection.
Kind and respectful care
Staff knew people's preferences and treated them warmly. Inspectors saw people supported with their appearance, privacy, dignity and religious beliefs.
“We found staff were warm in their interactions with people which were natural.” from the report
Personalised support
Care records included people's histories, preferences, routines, hobbies and interests. Plans were updated when people's needs changed.
“Care plans were changed in response to people's changing needs.” from the report
Good oversight
The management team used audits and checks to monitor care and follow up actions. People, relatives and staff were also given opportunities to give feedback.
“The home manager and district manager completed their respective audits and checks to enable them to monitor and improve the quality of people's care.” from the report
Covert medicines guidance
needs fixingGuidance for staff about how two people's medicines should be hidden was not detailed enough at the inspection. The provider later confirmed that pharmacy guidance had been added to the relevant records.
“We found there was insufficient guidance recorded for staff relating to how the medicine should be hidden.” from the report
Supervision records
minorMost staff had received recent supervision, but the records did not always clearly show personal development. Inspectors recommended making these records more consistent.
“We recommended the management team review the consistency in recording of supervision to ensure this contained clearer recording of personal development.” from the report
Manager vacancy
minorThere was no registered manager in post during the inspection. A home manager and acting deputy manager were providing cover, and interviews were taking place.
“did not have a registered manager in post.” from the report
Broken wall lights
minorThree wall lights in the ground floor lounge were not working. Managers said they would review this immediately.
“We observed three wall lights were not working in the ground floor lounge.” from the report
- 01Is a registered manager now in post, and if not, who is responsible for the home day to day?
- 02How do you check that staff supervision is happening and that personal development is recorded clearly?
- 03What changes were made to the records and pharmacy guidance for people receiving covert medicines?
- 04Have the three broken wall lights in the ground floor lounge been repaired?
- 05How are activities planned for each person, including people living with dementia?
This was an unannounced inspection over two visits covering all five CQC questions, including care, accommodation, records, medicines and management systems. This explanation was written from the published report of 27 February 2018 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 Tolson Grange
2 rated inspections over 3 years: the service has held its Good rating throughout.
- June 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 2010.
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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