Tudor Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People and those important to them were supported to understand safeguarding and how to raise concerns when they did not feel safe. Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to the manager. When concerns had been raised, the manager did not always report these promptly to the relevant stakeholders, there was no evidence to show lessons were being learnt following each incident. This meant that action was not always taken to prevent people from further risk. Safety risks to people were not always managed well. The manager completed risk assessments. However, not all high risks were individually assessed to meet people’s choices and preferences. Where care plans and risks assessments were created, the manager made sure people, and those important to them, were involved in making decisions about how they wished to be supported to stay safe. There were not always enough staff to support people with their needs. The deployment of staff had not been assessed to ensure staff were always present around the home. Staff received relevant training to meet the range of people’s needs at the service. Staff received support through supervision and appraisal to support their continuous learning and improve their working practice.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were positive around the learning culture that was embedded in the service. One relative told us, “Previously I wasn’t happy with the home at all, but the new owner has turned it around. They changed the care here in a positive way”. People and relatives told us, if an incident happened; staff included them in discussions, so it did not happen again.

Staff we spoke with told us how they were involved in learning lessons in the service. Staff told us, when an accident or incident happens, they all come together as a team and look at actions and planning to reduce the risk of re-occurrence in future. Staff did not always feel listened to around ideas they had for improvement of the home. One staff member told us, ‘” At times, it feels decisions are only made by the managers”. The management team told us how they review accident and incidents and look at themes and trends. However, this was not always effective in identifying reportable incidents to other agencies.

There were processes to review incidents. Staff were provided with the opportunity to reflect after incidents, to ensure learning and improvement could occur. Staff meetings allowed staff to reflect on what was working well, and what could be improved at the service. Accident and incidents did not evidence lessons learnt and what action had been taken after each individual incident.

People told us communication between staff and other health professionals was consistent. Routine visits from health professionals were embedded, for example, 1 person told us, ‘The district nurse comes every day to give me my injection or diabetes’. Some people and relatives told us they felt the care delivered was consistent and safely managed.

Staff knew how to monitor people’s health conditions, to ensure timely referrals were made to other services. For example, 1 person had grade 3 pressure areas on their skin, staff and the manager had ensured that district nurses were contacted, and a health management plan was put in place. Staff had good knowledge of which health and social care professionals supported which people. Staff were able to explain when these professionals visited, and what type of support they offered.

Partners told us, over the last 12 months they had worked closely with the service to improve systems. Partnership working took place, this included an action and improvement plan completed by the quality team and provider. Partners included in feedback how the service had improved and continued to improve.

The provider showed us the systems and processes to review the needs of people following a care package referral to ensure the service had the skills and capability to meet a service user’s care needs. This was carried out by the manager and provider. Once this had been agreed as potentially a good match the manager and provider would visit the service user and complete a full assessment of needs. Due to the home having an embargo on new admissions, we could not evidence or review this process during this assessment. When health professional visits were carried out, we had concerns around the information recorded. We found information conflicting, for example, where a nurse had provided advice and a routine for a person, this did not always transfer to the homes care plans or health notes. We raised this concern during the inspection and the manager told us they would communicate and monitor how staff complete records.

People told us they all felt safe living at Tudor Manor. People told us about past incidents and the action taken to keep them safe. One person who was blind had a complaints poster on the wall in front of them, however, they told us, ‘The procedure has never been read out to me, but I know I can speak to staff’. We raised concerns around this as this was not adapting to meet the needs of the person. The provider and manager told us they would look at accessible information and spend time to read and explain procedures. Some people would be at risk if they did not have continuous supervision and control, where this was the case, we saw the manager had applied for the suitable Deprivation of Liberty Safeguards. These safeguards ensure people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty.

Staff understood how to respond to allegations of abuse. Staff told us they had no concerns, but if they did, they were confident the management team would act appropriately. Staff were confident in using whistleblowing processes if they felt concerns was not being responded to. The manager understood how to respond to allegations of abuse. They had a clear process of how to investigate and keep people safe. Staff knew where to find the safeguarding policy. They were aware of the policy guidance and knew how to follow it to keep people safe from potential abuse.

We saw people and staff had positive relationships. There was an open culture of communication, and we saw no evidence that people were at risk of abuse. Staff demonstrated how to identify hazards around the home and how to minimise these to prevent the risk of injury or harm.

Systems and processes to protect people from abuse and neglect were in place. Staff were aware and understood the safeguarding policy. However, we did identify 3 missed reportable incidents that had not been reported to safeguarding or the CQC. We raised this to the manager, and they reported the incidents. Where saw incidents had been recorded, we saw they were investigated, and actions taken to keep people safe. Staff consistently reported incidents and accidents, which allowed a timely response to act on safeguarding concerns. Consent to care was not clearly evidenced in people’s care plans. People’s rights under the Mental Capacity Act 2005 were fully supported and understood by staff.

People told us that they were able to communicate their needs, to receive the right type of support. One relative told us, ‘We have been involved in the planning of their care and always involved in any reviews’. Some people told us they felt staff understood their needs well and provided the correct care to meet their needs.

The management team told us how they involved people, relatives and appropriate health professionals in identifying and assessing risks. We saw where additional needs for people were identified the manager and provider sourced additional training. For example, dementia, and management of falls. Staff told us they received regular training which provided them skills to provide the care people required. Staff told us they read care plan guidelines and were aware of the risks identified in the person’s care plan.

We saw people were supported safely. One person required mobility assistance from 2 staff when wishing to have a cigarette, we saw staff were quick to respond to this person and offered support that reduced the risk of any potential injury.

People’s needs were not always assessed and documented in their care plans. For example, 1 person who was prescribed emollient cream had no personal fire risk assessment. This meant that no control measures to keep the person safe and mitigate risks of fire were present. Staff kept clear records on how they had supported people and at what time. However, we saw/found gaps in records where essential monitoring was to be in place. For example, people who required fluid intake had fluid charts in place. The fluid charts had continuous gaps, we saw no action taken and the audits in place had not identified this concern. This had the potential risk of people being at harm of dehydration.

People told us the call bells in their bedrooms were always working and accessible. This meant they could request staff support if needed. Some people said that at times they have had to wait a short while before staff attend to assist them. People told us that the home met their needs and they had seen the environment improve over the last 12 months.

The management team described a clear process for monitoring the safety of the environment. For example, the home manager documented their regular checks around the building and explained how they would raise any concerns to the maintenance staff. We saw any actions raised had been resolved to keep people safe. We also saw areas that were under development to improve the home further.

Windows were unable to be opened wide. This safety feature prevents people from falling or climbing out and is in line with guidance from the health and social care executive. Some people at the care home used equipment (such as walking frames or hoists). We saw these pieces of equipment were well maintained and stored appropriately.

The environment was kept safe, by regular checks and maintenance. We saw there had been regular checks to ensure the home was safe in the event of a fire (for example, by checking the alarm systems.) The gas heating system was regularly serviced to prevent harm to people. People had access to call bells to call for support if needed. Documentation showed these call bells were regularly checked, to ensure they were working and effective. Some areas of the home that had been decorated recently with new carpets. However, these were not dementia friendly. For example, on the stairs and hallway a dark blue carpet was in place, this meant you could not identify the edges of the steps. We raised this with the provider and manager. The provider and manager took the feedback positively and told us they would review the areas of the home and look to make dementia friendly.

We received mixed feedback from people. Mostly people and relatives told us there were enough staff. One person told us, ‘There’s enough staff to care for me’. However, some people told us, there wasn’t enough staff. One person told us, ‘Some days it’s alright here. Sometimes there’s plenty of staff around and sometimes there’s only 2 staff. Usually there’s 3 staff but sometimes only 2’. A relative told us, ‘There’s definitely not enough staff, [Person] waiting for a chair to arrive. [Person] always has to wait to be hoisted as it takes 2 of them’.

Staff told us they had regular opportunities to meet their manager on a one-to-one basis for supervision. These meetings gave them the opportunity to feedback about their experiences and request further guidance or training if needed. Some staff we spoke with told us due to management changes over the last 12 months, staff were building relationships with leaders and gaining trust in the way they were leading.

We saw there were not enough staff to provide support to people safely. Staff were not deployed effectively around the building, to provide timely support to people. We raised this during the inspection and the manager and provider said they would look at the deployment of staff during each day. We raised issues where there were no staff present when assisting someone who needed support of two staff members. The manager told us they would be reviewing staffing levels and matching them to people’s needs.

The provider had used a calculation tool to assess how many staff were needed to meet people’s needs. The rota’s suggested these staffing levels had then been arranged according to this calculation. Staff had received suitable training to do their role. The management team ensured there was always suitably skilled staff working. The provider had in place a training plan for all staff to receive additional training and skill building. Once staff were trained, there were clear ongoing processes to assess their competency. If needed, further support and training was then given to improve staff skills. If staff were not providing the expected level of care, there were clear processes to monitor and improve their performance. Safe recruitment processes were mostly followed. Regular Disclosure and Barring Service (DBS) checks were carried out. These check the police database for convictions or warnings that may impact the staff members safety to work with people. However, we found also gaps in employment files. For example, references were not always obtained prior to starting employment with the provider.

People told us that the home was always kept clean. One person said, ‘” The home is clean and tidy, I like living here”.

Staff knew what personal protective equipment they should wear and when. Staff knew how to put on and remove this equipment, in a safe way. This protected people from the spread of infection. Daily checks were carried out to monitor the cleaning and infection control processes. Kitchen staff had completed food hygiene training which provided them with skills to ensure food was prepared and cooked meeting government standards of hygiene.

The home was clean and hygienic. We saw that staff had access to personal protective equipment (gloves, aprons) throughout the home. This allowed staff to support people in a hygienic way. The home had designated sinks for handwashing and in each area, there was handwashing guidance. The provider ensured risk to safety in the event of a fire were managed or fire risks were managed. Corridors were clear of any blockages, allowing people to follow escape routes.

There were processes and policies, to ensure the environment was kept clean and hygienic. This protected people from the spread of infection. Staff had received training in infection control, how to put on protective equipment and how to keep people safe in the event of an infection outbreak.

People told us staff gave their medicine at regular times, and as their prescription required. People told us they felt staff were trained well to help them with the management of medication.

Staff knew who to report medicine concerns too. For example, if they felt a person’s medicine was no longer effective, they understood where to document this, and which health professionals to contact. Staff told us how they involved health professionals when requiring additional support or where they had a concern.

Medicines were stored in locked cupboards to prevent people accessing them unsafely. There were no temperature records in peoples the individual medication cupboards or overflow medication cupboard. Medicines requiring storage in the fridge were stored in a locked medication fridge and temperature was regularly checked throughout the day. Some people at the service were prescribed controlled drugs. These are subject to enhanced restrictions due to the addictive nature of these medicines. We saw the provider had not followed national legal requirements by storing and auditing these medicines. No audit had taken place for the controlled drugs in the home, we raised this to the manager during our inspection, they actioned a weekly audit in place moving forward. Some people required ‘as needed’ medicine, written guidance on how this should be administered was not detailed. For example, 1 person was prescribed zopiclone ‘as required’ with no advice as to cut off time to administer – it is a night sedation therefore, administering it at 2 am might have unintended consequences. Staff kept records of when they had given prescribed medicines. We saw medicines were given as prescribed. Staff did regular checks of the amount of medicine in stock. This ensured that suitable stock levels were always in place, and more medicine could be ordered from the pharmacist as needed.