Tudor Manor

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

There were governance systems in place, however, these were not effective in identifying the concerns we identified/saw during this assessment. Staff understood their role and responsibilities. Managers accounted for the actions, behaviours, and performance of staff. Data or notifications were not always consistently submitted to external organisations as required. Leaders worked in partnership with local authorities and quality teams to improve the quality of care and service provided.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke with shared the values and vision for the organisation. Staff and management understood the importance of listening to the views of people and their relatives about the service. The provider and home manager we observed were working with the staff team to build open and transparent relationships and improve morale.

Processes ensured staff had a shared vision and values regarding the care and support delivered. People and their relatives had been provided with clear information on how to raise suggestions and concerns about the service. Surveys were sent out regularly to seek people’s views about the service, enabling them to contribute to its development. Risk assessment and care planning processes resulted in care plans acknowledging people’s diverse needs.

Staff told us the management team had improved and were accessible and approachable. Staff told us they felt supported and if they needed to speak to one of the management team, they were easy to contact. One staff member said, “I feel I can speak to the manager, if not I can always speak to the owner’. The management team understood how to promote safe recruitment practices, however, recruitment processes did not always have a robust audit to ensure all checks were present.

Supervision was provided to staff. The provider had regular check ins and supervisions with the manager of the home. Management was in the home daily, and when not around on the weekend, a senior was present at the home. A 24/7 on call system was in place. Where the home had required additional support, the manager or provider attended on weekends.

Staff told us they knew about the service’s whistleblowing policy and knew how to raise concerns. Staff were also aware they could report and concerns directly to the Care Quality Commission and the local safeguarding team.

There was a whistle blowing policy in place. Staff were informed about this as part of their induction. Staff could access the policy if needed at any time. People had information provided to them, this allowed them to know how to raise a concern and their right to speak up.

Staff felt the management team took into account their equality, diversity and inclusion and treated them fairly. For example, where staff needed to work in a flexible way, this was discussed with the manager and alterations to staffs working pattern would be made. Staff felt the home provided them with a good work life balance. Staff told us they attended regular staff meetings, which were productive and enabled them to openly raise issues and concerns.

The provider had policies and procedures around equality, diversity and inclusion. We found guidance and information was also available in the employee’s handbook.

The manager showed us they had a training tracker to monitor the compliance of the service. These were regularly checked and available for the provider to view as required. The manager had audits in place, these included medication audits, fluid audits, bowel audits and daily walkarounds. However, we found concern in the effectiveness of the audits as they had not identified the concerns we found during this assessment.

The provider’s governance systems were not always effective in enabling the management to have oversight, monitor and manage risks. Medication audits completed by management had identified concerns we did during this assessment. For example, medication audits had not identified that the home was not following NICE guidance to keep people safe. For example, there was no stock checks or monitoring of controlled drugs.

People and relatives told us staff assisted them in arranging support from other healthcare services as needed.

Staff and management we observed, collaborated with all relevant professionals, stakeholders and agencies, such as district nurses and general practitioners. We did have a concern with staff not always communicating or recording information provided from health professionals when they visit people. We saw where feedback had been actioned to improve the service after local authority involvement was in place.

The provider evidenced learning since the last inspection, however, we did identify areas that still needed improvement. Staff we spoke with told us about the improvements made to the home and the positive outcomes. However, some staff didn’t feel they were always involved in decisions. The manager had been in post for 4 months, they told us plans they had to introduce further monitoring and embedding of good practices they will be actioning. Unfortunately, during this inspection, these were not present to review.

Systems and processes to support learning and improvement in people’s care were in place. Incidents and accidents were reported and investigated. However, we saw a lack of action and evidence that learning for the future had taken place, and new ways of supporting had been adapted. During this assessment we found 3 reportable incidents that had not been reported by the manager, we shared our concern during the assessment, the manager submitted the referrals and told us they were missed. These were grading 3 pressure areas present on a person. Staff were appropriately supported to develop their skills and knowledge to improve the quality of care provided.