Tudor House

Updated 24 March 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.

As part of this inspection we looked at the infection control and prevention measures in place. This included checking the provider was meeting COVID-19 vaccination requirements. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The first inspection on the 25 January 2022 was completed by one inspector. The second inspection carried out on the 03 February 2022 was completed by one inspector.

Service and service type

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

The service did not have a manager registered with the Care Quality Commission. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

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. We sought feedback from the local authority and professionals who work with the service. The provider did not complete the required Provider Information Return (PIR). This is information providers are required to send us annually with key information about the service, what it does well and improvements they plan to make.

We reviewed any information on the Healthwatch website. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

We used all this information to plan our inspection.

During the inspection

We spoke with three people, one relative and three staff including the home manager and area manager. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and training. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

Five relatives and three staff members were contacted to gather their views on the care provided. We continued to seek clarification from the provider to validate evidence found.

Updated 24 March 2022

About the service

Tudor House is a residential care home registered to provide personal care for up to 23 people, some living with dementia. At the time of our inspection there were 19 people living at the home.

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

Since the last inspection there have been some changes to the management of the service and restructuring of its processes. We found some of the systems in place to monitor the quality within the home required improvement. The feedback we received from relatives and staff was mixed regarding how the service was managed and felt communication from the provider could be improved.

People we spoke with were happy with the care received. Relatives we spoke with were overall, satisfied with the support given to their family member.

People were protected from abuse and relatives we spoke with were assured the home environment was safe for their family members to live in. Staff knew how to report any suspicions of abuse. Risks to people were reviewed regularly and people were supported to remain as safe as possible.

On the day of inspection, there were enough staff employed to meet people's needs and there were recruitment procedures in place to check staff were safe to work with people.

People were supported to take their medicines in a safe manner. There were some minor issues with the recording and storage of medicines, however these had not posed any risk to people.

We were overall assured the provider had safe infection prevention and control procedures in place, including in relation to the management of COVID-19. The home environment was clean and tidy and no unpleasant odours.

Incidents and accidents had been reported appropriately and reviewed for any trends to mitigate future risk.

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 10 December 2019).

Why we inspected

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. This included checking the provider was meeting COVID-19 vaccination requirements.

We inspected and found there was a concern with some of the provider’s infection control practices, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe 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 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 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.

The provider had taken immediate action to address some of the concerns raised with them.

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 a breach in relation to the provider’s governance processes at this inspection.

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.