Tudor Grange

Tudor Grange is a residential care home providing personal care to 21 people at the time of the inspection. The service operates within an adapted building and can support up to 33 people.

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

People lived in an environment that was not always safe, and the provider’s safety monitoring checks were not always effective. Repairs were not always carried out in a timely manner and the cleanliness of the kitchen equipment and utensils was not satisfactory. Other communal areas and people’s bedrooms were clean, and staff understood how to prevent the spread of potential infections by following their infection control training.

People did not always receive their medicine in the way it had been prescribed, and the recording of controlled medicines was not always done correctly.

People were supported by staff who understood how to protect them from abuse. There were enough care staff available to meet people’s personal care needs. However, people were not always supported to access healthcare services in a timely way, and some relatives told us that they had needed to point out to care staff when a person required a visit to a GP. Care staff had not received training on how to support people’s oral healthcare needs.

Some people were not able to give their consent to live at the care home, but the records relating to the decision, taken on their behalf, were not always clear.

Notices, and written information, were not always easy for people to see and understand; or could be confusing for some people. Some relatives told us they wanted to be more involved in the planning of their relative’s care. The care home had electronic devices available that people could use to give feedback to the provider about the service; but some relatives told us they were not aware of the devices and did not know how to use them.

People enjoyed the food and drink provided; and were pleased with the variety offered to them. Care staff knew how to support people and had access to updated care plans to refer to if needed.

Care staff supported people with respect and kindness, and in ways which protected their dignity and independence. Relatives could visit people at any time and the care team encouraged people to maintain links with their families.

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.

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 requires improvement (published 20 October 2018).

Why we inspected

This was a planned inspection based on the previous rating.

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.

Following the inspection, the provider has taken effective action to reduce the potential risks to people caused by some of the environmental issues we found. This included improvements to kitchen cleaning and a repair to a faulty shower.

Enforcement

We have identified breaches in relation to the hygiene and maintenance of the property, the administration of prescribed medicines, and the provider’s processes for ensuring the quality of the service. 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Tudor Grange is registered to accommodate up to 33 older people with varying support needs, and people living with dementia. On the day of our inspection there were 26 people living at the service.

Tudor Grange 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. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run. The registered manager was present during the day of our inspection.

At our last inspection, on 1 August 2017 we rated the service as ‘Requires Improvement’. The service did not fully meet the fundamental care standards and was found to be in breach of Regulation 12 HSCA RA Regulations 2014 Safe care and treatment. This was because people who used the service were not protected against the risks associated with their care and support. Risk assessments did not fully include the information required to mitigate risks. People were also not protected from risks associated with the environment and medicines were not always administered safely and as required. The provider sent us an action plan informing us what action they planned to make and told us this would be completed by 31 October 2017.

At this inspection, we found the provider had taken the required action and the breach in regulation had been met. Whilst improvements had been made, further time was required for these to be fully imbedded and to ensure the sustainability of the improvements made.

Since our last inspection, improvements had been made to ensure people were protected from known risks. Staff had better guidance to support them to manage risks associated with people’s needs. Some improvements had been made to the environment with the completion of refurbishment work. Environmental checks on health and safety were not all up to date, but this was being addressed.

Since our last inspection, improvements had been made to the management of people’s medicines, but further work was required to ensure medicines were consistently and effectively managed. This included photographs for all people receiving support to manage their medicines and protocols, for medicines prescribed to be taken ‘as and when required’.

Staffing levels were sufficient on the day of the inspection, but concerns were identified in the deployment of staff. Communal areas were not always monitored leaving people at potential risk. Safe recruitment practices were followed.

Safeguarding procedures were in place to inform staff of how to recognise and report safeguarding concerns. The environment was clean and hygienic and staff followed best practice guidance in the prevention and control of cross contamination.

People had received an assessment of their needs that also considered their protected characteristics under the Equality Act, to ensure they did not experience any form of discrimination.

Staff received an induction and ongoing training and support, to enable them to provide effective care and support. Staff were positive about the training they had received and support from the registered manager.

People received sufficient to eat and drink. People’s preferences and nutritional needs were known and understood by staff and they received a choice of meals and were complimentary of the menu offered.

People’s health needs were assessed, planned for and monitored. Staff worked with external health care professionals to support people with their health needs. The service received weekly GP visits to support staff in people’s ongoing health needs.

People lived in an environment that considered their needs, aids and adaptations were available to meet people’s physical needs. People had opportunities to spend time with others in a choice of communal areas.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice. Staff were aware of the principles of the Mental Capacity Act 2005.

People were supported by staff who were caring, compassionate and who knew their needs, preferences and what was important to them. Staff respected people’s privacy and dignity. Advocacy information had been made available to people should they have required this support.

Care plans lacked guidance in places of the support required by staff and some gaps were identified in the assessment of people’s needs. End of life plans were not consistently recorded or discussed with people. The provider’s complaints procedure was available for people.

The systems and processes in place that monitored quality and safety, needed to be further developed within the service to ensure consistently. An action plan was in place to drive forward further improvements. People received opportunities to share their experience about the service they received.

The service is registered to provide accommodation with personal care for up to 33 older people with varying support needs, and people living with dementia. On the day of our inspection there were 27 people living at the service.

Tudor Grange 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. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run. At the time of our inspection a registered manager was in place and had been registered since September 2016.

Systems in place to reduce the risks associated with people’s care and support were not always effective. People were not protected from risks associated with the environment. People could not be assured that they received their medicines as prescribed. Concerns were identified with the staffing levels provided that these were insufficient in meeting people’s individual needs and safety. Immediate action was taken to increase staffing levels. People felt safe and staff were aware of safeguarding policies and procedures. Safe staff recruitment procedures were in place and followed.

Staff received an induction but said they struggled to find time to complete refresher training. Staff did not always receive suitable training or support to enable them carry out their duties effectively and meet people’s individual needs.

People’s rights under the Mental Capacity Act (2005) were not respected at all times. In addition, people could not be assured that they would be supported in the least restrictive way possible. Where people had capacity they were enabled to make decisions and their choices were respected.

People were positive about the food choices and had their hydration and nutritional needs assessed and planned for. People had access to healthcare and their health needs were monitored and responded to.

Staff were kind, caring and compassionate and had a good understanding of what was important to people living at the service. People felt involved with making choices relating to their care and were supported to maintain their independence. People were supported to maintain relationships with family and visitors were welcomed into the service.

People could not be assured that they would receive the support they required as care plans did not always contain accurate, up to date information. People were happy with the activities and opportunities available.

People and relatives were unsure of the complaints procedure and who and how, to report concerns to. Opportunities were available for people and their relatives to share their experience of the service.

People and relatives were not all sure who the registered manager was and staff felt there was poor leadership of the service and that they were unsupported.

Systems in place to monitor and improve the quality and safety of the service were not as effective as it could have been. However, an improvement plan was in place to address some areas of the service.

During this inspection we found concerns relating to the safe care and treatment of people and this was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We last inspected this service on 25 November 2014. At this inspection we found people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not always maintained. At this inspection we found the service had made improvements to their record keeping. Care staff told us they had received further training and support. The home manager said they regularly audited the completion of records and care staff had developed a way of recording relevant information in care plans taken from the person's daily records. A summary of what we found is set out below. We used the evidence we collected during our inspection to answer five questions.

Is the service safe?

One person who used the service told us they had moved downstairs because they were at risk of falling and increasingly unable to use the lift for moving between floors. Another person said, 'I feel safe here I started falling last year at home and broke my hip and would be frightened of falling again."

We spoke with a healthcare professional who was visiting someone in the home. They told us they had been visiting the home for several years. They said they had no concerns about the quality of care people received. They said they visited the home most days to see people and they thought the standards of care were good.

We spoke with three care staff who understood how to protect people who received care from abuse or neglect. Care staff told us they wanted to ensure people received safe, effective care.

We saw individual evacuation plans were posted inside each person's room. These identified the level of support the person needed to evacuate the building in an emergency, for example a fire.

There were no Deprivation of Liberty Safeguards (DoLS) in place at the time of our inspection. The Deprivation of Liberty Safeguards are a legal framework designed to ensure that the care people receive does not unlawfully deprive someone of their liberty. Care staff we spoke had received training in the Mental Capacity Act (2005) and were knowledgeable about the process required for assessing a person's mental capacity and making decisions in their best interest.

Is the service effective?

The visiting healthcare professional we spoke with told us the home provided effective support for people at the end of life. They said when they had been involved in end of life care planning people usually expressed a preference to stay in the home rather than be admitted to hospital. They said care staff were good at contacting them to obtain advice and acting on it. We found people's needs had been assessed and care plans were reviewed monthly. Care staff reviewed the support provided and identified if any changes to care plans were needed. Risk assessments had been carried out and were reviewed. Care was adjusted if a person's condition meant they required more support.

We found care staff had the appropriate training and experience to enable them to carry out their role effectively. Care staff told us they received regular supervision and appraisal. Care staff training was up to date.

Is the service caring?

We spoke with three people who used the service who told us care staff were considerate and respectful. One person said, 'I feel at home here and I know people will help me if I need help." We observed staff supporting people to eat their lunch. One person we spoke with told us they had previously stayed in another home but they thought the staff here were more helpful and caring. A relative we spoke with told us, "Staff really seems to care about people."

Some people told us they liked to spend time in their room and we found care staff visited them often to check if they needed a drink or to be re-positioned if they were in bed.

The service had carried out a survey of people's views about the service in 2014 which showed that 80% of the people who responded were happy with the support provided by care staff.

Is the service responsive?

On the day of our inspection the manager told us they were concerned about one person who was experiencing pain. Care staff had called the person's GP who agreed to issue a new prescription. We saw care staff had gone to collect the person's medicine which arrived a short time later.

We asked one person how responsive care staff were if they pressed the call assistance alarm. The person told us, 'I have sometimes had to wait for a while for anyone to come through the night but the last few times it has been much better. During the day it is fine.'

We spoke with one person who had brought their pet to live with them in the home. The person told us they were really pleased they could bring their pet with them to provide company and enable them to get out in the fresh air.

Is the service well-led?

Care staff told us their manager was supportive and approachable. The provider had systems in place to assess and monitor the service. The manager completed a number of monthly reports to the provider's head office. This included audits of people's care plans. Records showed managers from the provider's head office visited the home and audited care plans.

At our previous inspection we found that people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not always maintained. At this inspection we found the service had made improvements to their systems of record keeping.

The service carried out checks of equipment for moving and transferring people, for example, hoists. Arrangements were in a place for checking fire safety equipment and for protecting people in the event of a fire.

The views of people who used the service were sought and the manager had written to people and their relatives to inform them of the results. People were then informed about the actions the service intended to take based on the outcome of the survey.

We found that people were being respected and involved in their care. We found improvements in the way care and treatment was planned. We also found care and treatment was delivered in a way that was intended to ensure people's safety and welfare.

We found that the provider was ensuring that there was sufficient equipment available and that it was safe to use. We found improvements in the way staff were recruited to ensure they were safe to work with vulnerable people.

However, we found the care records confusing and were concerned with their accuracy and consistency.

People received the care and support they required to improve their health and well-being. However, care records were not written in enough detail to provide clear guidance to staff members, and reviews of care plans did not always evaluate the care provided and whether it was effective.

People were provided with a choice of meals and staff members assisted them appropriately with eating and drinking if this was required. They told us that their meals were always very nice.

Medicines were stored appropriately and records were maintained to show all storage areas were kept at the correct temperature. Administration records were kept and people received their medicines in a safe way.

Recruitment checks were all carried out or obtained prior to new staff members starting work with the service.

The service had a policy and procedure to guide people in how to make a complaint and information about taking complaints further. People told us they were able to make a complaint and that it would be dealt with.