Tilsley House Care Home

Updated 15 April 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was carried out by 2 inspectors.

Service and service type

Tilsley House Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Tilsley House Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with people who used the service and their relatives. We spoke with staff, including the registered manager, senior care staff, care staff and chef. We made observations of the service and reviewed care records. We reviewed documents relating to the management of the service.

Updated 15 April 2023

About the service

Tilsley House Care Home is a residential care home and was providing care to 25 people aged 65 and over at the time of the inspection. The service can support up to 32 people. Accommodation is laid out over 3 floors, there are bedrooms on each floor, some of which have en-suite facilities. The ground floor offers a spacious lounge, conservatory and dining space and there is level access to the rear garden. The registered manager's office can be found in close proximity to the lounge.

People’s experience of using this service and what we found

Recruitment procedures were not always robust to ensure staff were safe to work in the caring profession.

Staff were not always given clear guidance about how to protect people from the risk of harm.

Medicines were administered as prescribed but were not always disposed of safely.

There were not sufficient facilities available for staff to easily maintain good hand hygiene.

Food and fluid records were not always accurate, and people were not always supported with the correct equipment to eat enough.

The provider did not have effective systems in place to monitor the quality of the service and make required improvements.

People and their relatives were satisfied with how the service was run and spoke highly of the registered manager. Staff morale had improved.

There were enough staff to keep people safe.

People were confident their concerns would be listened to and addressed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service mostly supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 21 July 2021).

Why we inspected

We received concerns in relation to the quality of the care. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Tilsley House Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to person-centred care, safe care and treatment and good governance at this inspection.

We made recommendations in relation to recruitment and meeting nutrition and hydration needs.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.