25 January 2022
During an inspection looking at part of the service
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.