Tudor Manor

Updated 11 November 2023

Inspection team

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 three inspectors and an expert by experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Tudor Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both during this inspection.

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 there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return. 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 reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used this information to plan our inspection.

During the inspection

We spoke with 2 people, 11 relatives about their experience of the care provided. We spoke with 6 members of staff, including the nominated individual, carers, domestic staff and the chef. We spoke with one visiting professional who was a social worker.

We reviewed a range of records, this included 3 people's care records and multiple medication records. We looked at 5 staff files in relation to recruitment and supervision. We reviewed a variety of records relating to the management of the service, including policies and procedures.

The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Updated 11 November 2023

About the service

Tudor Manor is a residential care home providing personal care for maximum of 22 people. The service provides support to people aged 65 and provides dementia care to individuals. At the time of our inspection there were 20 people using the service.

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

Risks to people were not continually assessed and mitigated. Fire safety practices were not robust. There was a lack of oversight and monitoring of daily care. Safeguarding concerns were not consistently escalated to external professionals. Systems and processes to safeguard people from the risk of abuse were not embedded in the home. .

Staff were not recruited safely, safety checks carried out on individuals employed by the home were not carried out to ensure vulnerable people living in the home were safe.

There were infection control measures in place, however we were not assured the provider had considered shielding and social distancing rules, when people shared bedrooms. Accidents and incidents were recorded but not analysed for themes and trends. People received their medications as prescribed. Relatives were encouraged to visit their loved ones.

The provider lacked understanding around the Mental Capacity Act, we found that people were not correctly assessed for their mental capacity, meaning decisions people could make were unclear. Care records lacked personal characteristic and information about how to support people with specific health needs. We found people who were receiving respite care did not have a care plan in place.

Staff training records showed gaps in mandatory essential training, meaning staff were not fully trained.

Staff worked with external professionals to promote a partnership approach to care. However, staff did not always escalate concerns in a timely manner. The service had not been adapted to meet people’s needs and lacked person centred detail.

People were supported to eat and drink and told us they enjoyed the food. People had choices in the food they ate and could change their mind and have alternative meals.

Improvements were needed to ensure people’s end of life documents were up to date and reflected their wishes. The provider did not always explore the most effective way to communicate with people.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement 11 February 2022.

At our last inspection we found breaches of the regulations in relation to good governance. The provider completed an action plan after the last inspection to tell us what they would do and by when to improve.

At this inspection, we found the provider remained in breach of regulations.

Why we inspected

We received concerns in relation to the management of the service and people’s safety. As a result, we undertook a focused inspection to review the key questions of safe, effective, responsive, 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 requires improvement to inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements.

Please see the safe, effective, responsive 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 Tudor Manor on our website at www.cqc.org.uk

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.

Enforcement

We have found breaches in relation to safe care and treatment, safeguarding people from abuse and improper treatment, need for consent, fit and proper persons employed and good governance.

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

The overall rating for this service is inadequate and the service is therefore in special measures. This means we will keep the service under review and will re-inspect within six months of the date we published this report to check for significant improvements.

If the registered provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question, we will take action in line with our enforcement procedures. This usually means that if we have not already done so, we will start processes that will prevent the provider from continuing to operate the service.

For adult social care services, the maximum time for being in special measures will usually be 12 months. If the service has shown improvements when we inspect it, and it is no longer rated inadequate for any of the five key questions, it will no longer be in special measures.