Tiltwood

Tiltwood is a residential care home providing personal care for up 50 people. The service provides support to older people who are living with dementia. At the time of our inspection there were 42 people using the service. Accommodation is arranged into 5 individual suites, each with their own communal dining and sitting areas. During the day, people also have access to a range of internal and external activity spaces.

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

We identified that the physical environment was not wholly suitable for people living with dementia and have recommended that the provider consider best practice as they undertake their planned changes to the design and decoration of the service.

There were systems in place to keep people safe. People were safeguarded from the risk of abuse or avoidable harm. The management team had appropriately assessed risks and staff took action to protect people.

People were supported by a team of staff who knew them well. Appropriate steps were taken to ensure staff were suitably vetted prior to appointment. Staff completed regular training and coaching was ongoing to ensure staff had the skills and experience to support people effectively.

People were supported to have 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 supported this practice.

The provider’s governance systems had improved and were being continuously used to improve the service.

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

Rating at last inspection and update

The last rating for this service was Good (published 7 June 2018).

Why we inspected

The inspection was prompted in part due to concerns received about the management, staffing and safety of the service. A decision was made for us to inspect and examine those risks. 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.

We found that the provider needs to make improvements as outlined in the Effective key question. However, the provider was aware of the areas requiring improvement and had already taken significant action against these. We therefore found no evidence during this inspection that people were at risk of continued harm from these concerns.

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

Follow up

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

The provider had implemented measures to reduce the risk of infection. Staff were observed wearing appropriate Personal Protective Equipment (PPE) and they received ongoing training in its correct use.

The service was clean and hygienic. Dedicated domestic staff were allocated to each shift to ensure the continuous cleaning of high-touch areas such as door handles, hand rails and switches, in addition to maintaining good levels of cleanliness throughout.

The provider had an infection prevention and control (IPC) policy and regular IPC audits were carried out to ensure appropriate standards in this area were maintained.

The registered manager had taken action to minimise risks to people who used the service, staff and visitors. Risk assessments had been carried out to identify and mitigate risks, including for people in vulnerable groups.

The testing of people, visitors and staff was undertaken in line with government guidelines. If staff returned positive test results or had Covid symptoms, they did not return to work until they had completed the required period of self-isolation.

People had received their Covid vaccinations. Where people lacked the capacity to consent to either their vaccines or testing, the registered manager had ensured decisions were made following best interests' principles.

If people displayed symptoms or tested positive for Covid, staff encouraged them to self-isolate in their bedrooms. Where this was not possible, people were supported to remain on their own units to minimise the risk of spread across the service.

Staff supported people to access the healthcare treatment they required. The registered manager had good links with the allocated GP who had continued to visit the service at least every week.

Staff had been well supported during the pandemic through the provision of information and guidance, at team meetings and at individual meetings.

We found the following examples of good practice:

The staffing model had been adapted to ensure people received consistent support and minimised the risk of cross-infection across the service.

The inspection took place on 12 March 2018 and was unannounced. There were 40 people using the service at the time of our inspection.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had been in post since November 2015.

We previously carried out an unannounced comprehensive inspection of this service on 15 March 2017. At that inspection we found one breach of legal requirements in respect of providing person centred support. As a result the findings from that inspection, the service was rated Requires Improvement. The provider sent us an action plan which identified the steps they intended to take to make the required improvements and this inspection confirmed that the provider had done the things they told us they would.

This inspection found that whilst people were experiencing a good standard of service, some staff did not always have the skills and confidence to meet people’s specialist needs. In addition, staff needed to ensure they always worked collaboratively to make sure they delivered the most effective support. The registered manager and provider had already identified these areas of improvement and plans were in place to ensure they were acted upon.

People now experienced a personalised approach to care and most staff had a good understanding about their wishes. Each person had been appropriately assessed and information used to develop a plan of care that outlined how support was to be provided safely and in accordance with people’s preferences. People were given choice and control over how they lived their lives and their right to be independent was inspected.

People were supported to lead healthy lives and encouraged to eat and drink so as to maintain a healthy and balanced diet. The registered manager worked in partnership with other healthcare professionals to ensure people received holistic care. Medicines were managed safely and people received their medicines as prescribed. End of life care enabled people’s final wishes to be respected and allowed people to pass with comfort and dignity.

Staffing levels were sufficient to safely meet people’s needs. Appropriate checks were undertaken to ensure staff were suitable to work people and training and support was provided to enable them to deliver their roles.

Staff understood their responsibilities in protecting people from harm and there were appropriate systems, processes and practices to safeguard people from abuse. Risks to people were identified and managed in a way that balanced both people’s safety and freedom.

The environment was suitable for people’s needs and the Registered Manager was continuously developing the sensory areas around the service. The service was clean with good infection control systems in place.

The atmosphere in the service was relaxed and people were treated with kindness and compassion. Staff respected people’s privacy and took appropriate steps to ensure their dignity was upheld. People had opportunities to participate in activities that were engaging and meaningful to them and their friends and families were welcomed into the service.

The culture within the Tiltwood was open and inclusive people and their representatives felt empowered and engaged in the running of the service. There were effective systems in place to ensure that people were listened to and concerns were addressed in a way that improved the quality of care.

The registered manager actively championed highly personalised support and took appropriate steps to ensure lessons were learned when things went wrong. The governance framework at both provider and management level ensured regulatory requirements were understood and complied with.

The inspection took place on 15 March 2017 and was unannounced. There were 42 people using the service at the time of our inspection.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had been in post since November 2015.

We previously carried out an unannounced comprehensive inspection of this service on 4 November 2015. At that inspection we found one breach of legal requirements in respect of staffing levels and a requirement action was set. We also made recommendations that the provider take steps to improve the outside safety of the service, support staff to better manage people’s anxieties and develop more meaningful activities. As a result the findings from that inspection, the service was rated Requires Improvement. The provider sent us an action plan which identified the steps they intended to take to make the required improvements and this inspection confirmed that the provider had done the things they told us they had.

At this inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report. This report also highlights that the registered manager was in the process of implementing a further number of changes to improve the quality of support provided. For example, the deployment of a senior team leader to more closely coach and monitor staff practices, specific training for staff in managing challenging behaviour and the personalisation of people’s rooms and living spaces. We expect these changes to be fully embedded over the coming months and will monitor the service against them at our next inspection.

People experienced varied quality of support at Tiltwood. As such, we found differences in the care and support that people received both across different units and between different staff. In one unit, the quality of some people’s care was compromised by the high needs of one person. This meant that other people did not always receive the same level of support and attention they required.

Whilst there were systems in place to train and support staff, these was not always consistently reflected in the behaviours and practices of staff. For example, some staff had an excellent understanding of people’s needs and engaged effectively with people. Other staff however, lacked either the necessary skills or empathy to effectively support older people living with dementia.

People’s care records did not always provide easy access to current and detailed guidance about how to support people. Good communication between staff mitigated some of the risks associated with this, but some people did not receive the most personalised and consistent support.

Staff were working hard to improve the quality of activities across the service and many were seen to take opportunities to engage with people in a positive and creative ways. Whilst staffing levels were now safe, the quality of people’s social experiences were affected by both the availability and skill of the staff deployed to work with them.

Risks to people were assessed and actions taken to manage avoidable harm. The processes in place to safeguard people were effective and the registered manager and staff had a good understand about their roles and responsibilities in protecting people from abuse.

New staff were subject to a series of recruitment checks and completed a recognised programme of induction before working alone with people. Staff told us that they were well supported by each other and the registered manager in the delivery of their work.

People were supported to access the healthcare support they required and medicines were managed safely. Senior staff had good knowledge about people’s healthcare needs and the importance of managing people’s pain or medical needs. People had some choice over their meals and were effectively supported to maintain a healthy and balanced diet.

The atmosphere across the service was relaxed and friendly and overall staff respected people’s privacy and dignity. People were encouraged to make express their wishes and staff understood the importance of allowing people to make their own decisions. The registered manager had worked hard to ensure staff delivered care in the least restrictive way.

The registered manager was widely respected by people, relatives and staff alike. She was hands on in her approach and a positive role model for staff. The management style had a fostered a more open culture throughout Tiltwood where people were encouraged to share their views with confidence that they would be listened to and acted on. Systems for monitoring quality and auditing the service had improved and were being better used to develop the service.

We found during our inspection in June 2013 that full recruitment procedures had not been followed by the provider. During this inspection we found that the concerns that had been identified then had now been addressed.

People who lived at this home indicated that staff gained their consent to care, and that their care needs were well catered for. Comments on this question included 'Staff are pretty good' and 'Yes, we do get the help we need.'

We asked people if they felt safe living at this home and they told us that they did feel safe. One person added 'Yes, quite safe.'

Some people told us they had been involved in the recruitment of new staff and said the manager 'Did bring new staff to meet us.' However, we noted some shortfalls in relation to the recruitment records we sampled.

People we spoke with said they would know how to make a complaint if they had one. One person who told us they would report any concerns to the manager added 'She is so nice and would make sure everything was alright.'

The inspection on the 25 January 2013 focussed on checking that records and quality assurance processes had improved and improvements to the quality of the service had taken place.