Tollesby Hall Nursing Home

At the last inspection in February/March 2023, we rated the home as requires improvement due to a breach of regulation. This breach related to the provider not maintaining accurate and complete records concerning the service and people’s care. The purpose of this inspection was to follow up on that regulatory breach. At this inspection, we found that improvements had been made, and the provider was no longer in breach of regulation. We rated the provider as good.

Staff responsible for the administration of medicines had received training. People received their medicines safely.

On the first day of the assessment, we found some areas of the service needed a deep clean. When we returned for our second day, these areas were seen to be much cleaner.

Safe recruitment procedures were in place. Safeguarding investigations were detailed with lessons learnt.

We gathered information from people who used the service, relatives, the management team, staff and health and social care partners. Everyone was positive about the care and support provided. Staff were knowledgeable about people’s needs, as was the manager.

Some areas of the home had been redecorated. The provider had a refurbishment plan in place which covered areas of the service that were yet to benefit from refurbishment. This included bedrooms and communal areas.

MCA assessments and best interest decisions were in place, but required some further detail.

Care records identified evidence of working with other health and social care professionals. Care assessments and other monitoring tools were completed for people.

Staff were kind, caring and patient and encouraged people with their independence. Care plans were individualised and detailed to help ensure the care needs of the person were met.

Complaints were investigated and responded to. The staff received many compliments from people and family. Systems were in place to monitor the quality of the service and identify improvements.

There was a registered manager for this service, who was due to move permanently to a management role in another service operated by this provider. The provider had recently appointed a new manager, who was in the process of submitting their application to CQC. The newly appointed manager had worked at Tollesby Hall for 5 years as clinical lead.

The service had recently been awarded the Gold Standards Framework Platinum Award. This is awarded to organisations that show sustained excellence in end-of-life care. The manager and staff were very proud of their achievement.