Tudor Manor

Tudor Manor is a residential care home providing personal care for maximum of 22 people. The service provides support to people aged 65 and provides dementia care to individuals. At the time of our inspection there were 20 people using the service.

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

Risks to people were not continually assessed and mitigated. Fire safety practices were not robust. There was a lack of oversight and monitoring of daily care. Safeguarding concerns were not consistently escalated to external professionals. Systems and processes to safeguard people from the risk of abuse were not embedded in the home. .

Staff were not recruited safely, safety checks carried out on individuals employed by the home were not carried out to ensure vulnerable people living in the home were safe.

There were infection control measures in place, however we were not assured the provider had considered shielding and social distancing rules, when people shared bedrooms. Accidents and incidents were recorded but not analysed for themes and trends. People received their medications as prescribed. Relatives were encouraged to visit their loved ones.

The provider lacked understanding around the Mental Capacity Act, we found that people were not correctly assessed for their mental capacity, meaning decisions people could make were unclear. Care records lacked personal characteristic and information about how to support people with specific health needs. We found people who were receiving respite care did not have a care plan in place.

Staff training records showed gaps in mandatory essential training, meaning staff were not fully trained.

Staff worked with external professionals to promote a partnership approach to care. However, staff did not always escalate concerns in a timely manner. The service had not been adapted to meet people’s needs and lacked person centred detail.

People were supported to eat and drink and told us they enjoyed the food. People had choices in the food they ate and could change their mind and have alternative meals.

Improvements were needed to ensure people’s end of life documents were up to date and reflected their wishes. The provider did not always explore the most effective way to communicate with people.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement 11 February 2022.

At our last inspection we found breaches of the regulations in relation to good governance. The provider completed an action plan after the last inspection to tell us what they would do and by when to improve.

At this inspection, we found the provider remained in breach of regulations.

Why we inspected

We received concerns in relation to the management of the service and people’s safety. As a result, we undertook a focused inspection to review the key questions of safe, effective, responsive, and well-led..

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 requires improvement to inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements.

Please see the safe, effective, responsive 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 Tudor Manor on our website at www.cqc.org.uk

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We have found breaches in relation to safe care and treatment, safeguarding people from abuse and improper treatment, need for consent, fit and proper persons employed and good governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is inadequate and the service is therefore in special measures. This means we will keep the service under review and will re-inspect within six months of the date we published this report to check for significant improvements.

If the registered provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question, we will take action in line with our enforcement procedures. This usually means that if we have not already done so, we will start processes that will prevent the provider from continuing to operate the service.

For adult social care services, the maximum time for being in special measures will usually be 12 months. If the service has shown improvements when we inspect it, and it is no longer rated inadequate for any of the five key questions, it will no longer be in special measures.

Tudor Manor is a residential care home providing personal care to 16 people aged 65 and over at the time of the inspection. The service can support up to 22 people in one adapted building.

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

The home environment was clean and well maintained. We found multiple wall radiators in some people’s bedrooms and communal areas were without covers to mitigate the risk of burns. Locks on bedrooms doors and window restrictors required replacing to meet British Safety Standards. Medicines management required some improvement to make sure appropriate processes were in place to monitor medicine stock levels. The provider’s quality assurance systems were not always effective at identifying areas for improvement.

Other risks, such as risk associated with people's mobility and health conditions had been assessed. Care plans were in place and in the process of being reviewed.

People we spoke with told us they felt safe from the risk of abuse. Family members told us they felt their relatives were safe living at the home and spoke positively about all the staff that supported their relatives. Staff understood their responsibilities to keep people safe and safeguarding concerns were referred to the local authority.

Incidents and accidents had been monitored for future learning.

There were enough staff on duty to meet people's needs and recruitment processes were in place to safely recruit staff. We found there was good communication with healthcare agencies. We saw kind interactions with people.

People’s care and support needs had been appropriately assessed and their nutritional needs were being met. Health and social care professionals confirmed the service worked in partnership with them to maintain people’s health and support needs.

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.

Staff felt supported by the registered manager. Staff had received supervision to help them in their roles and training had been completed or in the process of being arranged for them.

The registered manager understood their regulatory responsibilities.

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 22 November 2018).

Why we inspected

We received concerns in relation to infection control, staff training, medicines management, building maintenance and recruitment processes. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe 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 Tudor Manor on our website at www.cqc.org.uk.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At our last inspection on 14 December 2015 we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

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The inspection visit took place on 12 October 2018 and was unannounced. The inspection took place partly in response to some concerns raised with us around staffing issues and that people were not receiving appropriate support. During the inspection we found no evidence that people were not being adequately cared for and the recruitment of staff was in process.

The registered manager had left their post during the week of the inspection and therefore they were not present on the day. 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 quality director had taken on the role of acting manager in the period leading up to a new registered manager being employed.

People continued to receive care that made them feel safe and they received medicine as required. Staff understood how to protect people from abuse and harm. Risks to people were assessed and guidance about how to manage these was available for staff to refer to/follow.

People continued to receive effective support from staff with a sufficient level of skills and knowledge to meet their specific needs. People were supported to have choice and control of their lives and staff supported their choices. People were assisted to access appropriate healthcare support and received an adequate diet.

The care people received was provided with compassion and dignity. People were supported to express their views. Staff supported people to have choices and independence, wherever possible. People’s diverse needs were recognised and staff enabled people to access activities should they so wish.

The provider had effective systems in place to regularly review people’s care provision, with their involvement. People’s care was personalised and care plans contained information about the person, their needs, choices and preferences. Care staff knew people’s needs and respected them. People were able to speak openly with staff and tell them if they were unhappy or wanted to make a complaint.

The service continued to be well-led, including making detailed checks and monitoring of the quality of the service. People and staff were positive about the leadership skills of the management team. Arrangements were in place to obtain views on the service from people, staff and their relatives.

Tudor Manor provides accommodation for up to 22 older people who require personal care. On the day of our inspection there were 22 people living there.

There was a registered manager in post and she was present during our inspection. 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 and associated Regulations about how the service is run.

People were positive about the care they received and they all told us they felt safe. People told us that staff knew them well and supported them in their preferred way. We saw that staff had developed a good rapport with people who used the service. People commented on the homely atmosphere within the home.

The staff had a clear awareness and understanding of potential abuse and knew how to protect people from the risk of harm. There was enough skilled and experienced staff to meet people’s needs. Staff were recruited in a safe way which ensured they were of a good character to work with people who used the service.

Risk assessments and care plans had been developed with the involvement of people. Staff had the relevant information on how to minimise identified risks to ensure people were supported in a safe way. People had equipment in place when this was needed, so that staff could assist them safely.

The manager understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff knew about people’s individual capacity to make decisions and supported people to make their own decisions.

People were treated with kindness, compassion and respect and staff promoted people’s independence and right to privacy. People were supported to maintain good health; we saw that staff alerted health care professionals if they had any concerns about their health. People knew how to make a complaint and were confident that their complaint would be fully investigated and action taken if necessary.

People described the management team of the home as approachable and they said they felt the service was well managed. Arrangements were in place to assess and monitor the quality of the service, so that actions could be put in place to drive improvement. The management of the service was open and transparent.

People were very positive about the care and support being provided. One person said, 'The staff are very good. Nothing is too much trouble.'

People told us that there was a good choice of food and we saw there were procedures in place to monitor the intake of food and fluids to lessen the risks associated with inadequate nutrition and hydration.

We found that appropriate arrangements had been made to manage the risks associated with the unsafe use and management of medicines.

Recruitment and selection processes were in place to ensure that suitable staff were employed to look after people. People we spoke with were very complimentary about staff. One person said, 'They (staff) go out of their way to help you.'

The provider had improved the quality monitoring systems that were now better designed to assess and monitor the quality of service that people receive.