Archived: The Tudors

Updated 20 October 2022

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 Health and Social Care Act 2008.

Inspection team

The inspection was carried out by one inspector.

Service and service type

The Tudors 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. The Tudors is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection a manager had been appointed and had planned to register with the Care Quality Commission. This had been postponed due to changes within the organisation.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. This included the statutory notifications the provider had sent to CQC. A notification includes information about important events which the service is required to send us by law.

We reviewed 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 the manager and maintenance person about the specific concern we were inspecting. We spoke briefly with people who lived at the service, staff and visiting professionals.

We looked at checks which were carried out of the environment and equipment, policies and documents relating to people’s safety in the event of an emergency. We looked around the building and grounds. We considered all of this information to help us to make a judgement about the service.

Updated 20 October 2022

About the service

The Tudors is a residential care home providing accommodation and personal care to up to 21 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 16 people using the service.

The Tudors is in an adapted residential building with individual bedrooms on two floors, ground floor communal spaces and a rear garden.

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

People could be at risk of harm in the event of an emergency situation because health and safety standards were not always assessed and maintained in accordance with legislation and guidance. Risks included fire doors which did not comply with regulations, an ineffective evacuation strategy and lack of practical staff training and knowledge.

Risks to people were not always managed safely. Risk assessments relating to the health, safety and welfare of people using services were not complete or reviewed regularly. This meant staff did not have current guidance to support them in caring for people.

Medicines were not always managed safely. This included the ordering, safe storage and management of medicines. Audits had been carried out but had not always identified the shortfalls we found during our inspection.

Staff had received training, but some information was not well understood or embedded in their everyday practice. We have made a recommendation about staff training and comprehension. Staff were beginning to receive supervision and consistent support.

Governance processes were not always effective because they had not been consistently and robustly embedded. Improvements were not introduced because standards had not been regularly monitored.

There had been several changes within the management team which had led to a lack of consistency and oversight. Concerns had not always been identified relating to the safety, quality and standard of the service. Monitoring systems and processes had been introduced, but these were not yet carried out consistently or embedded. The new management team appeared open to feedback and were keen to make improvements.

There were enough staff to support people safely, and staff knew people well. Safe recruitment practices were in place, and work was underway to standardise staff personnel files.

People were kept safe from COVID-19 and other infection outbreaks effectively. Improved cleaning regimes and recording was needed in some bedrooms and bathrooms.

People were kept safe from avoidable harm and staff told us they would take action if they had concerns about abuse or risk to people.

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 management team were keen to develop an open and positive culture within the service. They aimed to keep people and their families at the heart of what they did and worked with staff to ensure they provided high quality care.

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 14 July 2021).

Why we inspected

We received concerns in relation to the safety of the building, fire safety, staffing and management oversight of the service. As a result, we undertook a focused inspection to review the key questions of safe 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 based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. 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 The Tudors on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the safe care and treatment of people who lived at the service, the premises and equipment, management systems and monitoring. Please see the action we have told the provider to take at the end of this report.

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

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.