Tollesby Hall Nursing Home

Updated 20 June 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 Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Three inspectors and an Expert by Experience carried out this inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Tollesby Hall Nursing 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. Tollesby Hall Nursing Home is a care home with 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

Inspection activity started on 16 February 2023 and ended on 27 March 2023. We visited the home on 16, 20 February and 15 March 2023.

What we did before the 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 17 people and 3 relatives about their experience of the care provided. We spoke with 13 members of staff including the nominated individual, the registered manager, the deputy manager, 2 nurses, an administrator, cook and 6 care staff. We made telephone calls and emailed a further 8 staff with 2 staff offering feedback. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We looked at the care records of people, a sample of medicines records and other records related to the management of the home.

Updated 20 June 2023

About the service

Tollesby Hall Nursing Home is a residential care home providing personal and nursing care to up to 55 people. Over the period of our inspection there were between 53 and 47 people using the service.

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

People and relatives gave mixed feedback about the care and support received. Some people remarked that staff supported them as requested. Whilst others told us they had lack of choices especially about personal care.

Care records were not always complete and accurate. Daily records did not always document actions taken to address gaps within people’s personal care and catheter care. Elements of the poor record keeping had been identified by the registered manager, who had started to address the failings. However, issues were still evident during the inspection. CCTV control measures were not effective. The provider’s annual review of the systems had not identified the issues we found.

Permanent staff were recruited safely. Staffing levels were calculated using a dependency tool which looked at the needs of each person. People and relatives gave mixed comments about how responsive staff were. Some people told us staff were readily available whilst others told us they had to wait. The registered manager advised that staffing levels were regularly reviewed, and staff were allocated duties daily, dependent on people’s current needs.

The home had a system to investigate and record safeguarding incidents. Staff had completed safeguarding training.

Information gathered from accidents and incidents was analysed to identify trends or patterns with actions put in place to minimise risk of further incidents.

The home was clean and tidy. Staff had completed training in infection control and followed protocols to reduce the risk of infection.

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 supported this practice.

The registered manager and staff were passionate about providing quality end of life care. The home had achieved the Gold Standards Framework (GSF) Accreditation Quality Hallmark Award. GSF provides effective end of life care training for the care team and promotes better working with external healthcare professionals.

The provider and registered manager understood their duty of candour. The home had developed strong partnerships with health and social care professionals to ensure people received joined up care. Feedback from healthcare professionals spoke positively about the care provided especially about end-of-life care.

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 1 December 2017).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We undertook a focused inspection to review the key questions of safe, caring 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. This is based on the findings at this inspection.

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

Enforcement and Recommendations

We have identified a breach in relation to the failure to maintain accurate and complete records in relation to the service and people's care.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.