Tudor Lodge

Updated 18 November 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 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 inspection was completed by one inspector.

Service and service type

Tudor Lodge 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 Lodge 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 3 October 2022 and ended on 11 October 2022. We visited the service on 3 October 2022.

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. We used 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 seven people and four relatives about their experience of the service. We observed staff interactions with people in the communal areas. 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 spoke with seven members of staff including the provider, registered manager, deputy manager, nominated individual, senior carers and kitchen assistant. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included four people’s care plans and all the medication records. We looked at four staff files in relation to recruitment. A variety of records relating to the management of the service, including checks and audits.

Updated 18 November 2022

About the service

Tudor Lodge is a residential care home providing care and accommodation for up to 44 older people living with dementia, in one large adapted building. At the time of our inspection there were 40 people using the service.

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

People appeared to be happy and relaxed in the company of staff. People told us they felt safe with staff. Relatives told us they thought their loved ones were safe and well looked after.

Potential risks to people’s health and welfare had not been consistently assessed, there was not always detailed guidance for staff to mitigate risks. Accidents and incidents had been recorded and analysed, however, there was not consistent records of the action taken to reduce the risk of them happening again.

Medication was not always managed safely, people had not always received their medicines as prescribed. Staff were recruited safely, there were enough staff to meet people’s needs. However, there was not a consistent system to calculate the number of staff required when people’s needs changed.

Audits had been completed to check the quality of the service, however, these had not been effective in identifying extent of the shortfalls found at this inspection. There had not been a comprehensive action plan in place to rectify any shortfalls found.

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.

There were systems in place to protect people from discrimination and abuse. The registered manager had reported incidents to the local authority as required and worked with them to reduce the risk of them happening again.

Relatives told us they were confident to discuss any concerns with the registered manager and had been kept informed of incidents and their relatives health. Relatives visited when they wanted and were supported to take people out. Staff were wearing personal protective equipment in line with government guidance.

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 31 December 2020).

Why we inspected

We received concerns in relation to management of risk and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

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.

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 Lodge on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to risk management, medicines and governance at this inspection. Please see the action we have told the provider to take at the end of this report.

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.