Tudor Lodge

Updated 7 August 2019

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 Care Act 2014.

Inspection team

The first day of this inspection was carried out by an inspector and a specialist professional (nurse) advisor (SPA). An inspector returned on the second day to conclude the inspection.

Service and service type

Tudor Lodge is a care home. People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. A manager registered with the Care Quality and the provider are 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 on the 28 June 2019 and announced on the 1 July 2019.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

In addition, this included we looked at the information we held about incidents the provider must notify us about, such as abuse; and we sought feedback from the local authority. We also requested feedback from Healthwatch to obtain their views of the service. 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 spent time with people in the communal areas of the home to see how staff supported people they cared for. We spoke with four people who lived at the home about their experiences of the care and support provided.

We talked with the registered manager, deputy manager and two staff [support workers].

We looked at a range of records. These included sampling three people's care records and people’s medicine documentation. We also looked at staff training, meetings held with people who lived at the home and staff, records associated with the management of the service.

After the inspection

We spoke with the registered manager’s line manager via the telephone and received emails from both the registered manager and their line manager sharing information with us regarding the concerns highlighted during the inspection visits.

Updated 7 August 2019

About the service

Tudor Lodge is a care home that provides nursing and personal care for up to seven people

within one large adapted building. It provides care and rehabilitation for people with mental health care needs. At the time of our inspection, six people were living at the home.

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

The registered manager and provider did not always ensure their quality assurance checks were consistently strong and effective in reducing risks to people’s health and safety and records were accurate.

The risk of infections were not always effectively reduced by the arrangements in place to clean specific parts of the home environment including shower areas.

Although people were supported to take their medicines the checks undertaken to ensure these were administered as prescribed were not consistently effective to ensure people’s safety was not compromised.

The risks to people’s safety regarding the storage of hazardous items was not always effectively managed with actions taken to reduce the risk of preventable harm.

Staff spoke very affectionately about the people they cared for and supported. People were confident to request support and reassurance from staff when they wanted this and; staff took time to provide this in the ways people preferred.

Staff had received training and developed the skills they needed to care for people, through induction and on-going training. People told us staff knew how to support them and knew what to do if they suspected anyone was at risk of harm including discrimination due to their individual needs.

People's individual needs and requirements were assessed prior to them moving into the home. People had support to eat and drink safely and comfortably. The ethos of the registered manager and staff was to promote people’s independence in all aspects of their life including preparation and cooking of meals.

People had access to other health and social care professionals, so their needs could be monitored and met. 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. Staff respected people’s rights to make their own decisions about their lives and care. Where people needed support to make some decisions staff assisted them, using people’s preferred ways of communicating.

Staff supported people with compassion and understanding. People had support to express their views and opinions, and support was provided with dignity and in private.

The views of people were considered when their care was assessed, planned and reviewed, so people’s preferences were responded to and met. Staff ensured people had opportunities to do things which they enjoyed, which also met their emotional, social and psychological needs. People were supported to keep in touch with others and religious practices that were important to them. People’s wishes for their care at the end of their lives had been planned with them, so their preferences were known and met at this important time.

People knew how to raise any complaints and/or concerns they had and were confident the registered manager and staff would support them to resolve these.

The registered manager promoted an open culture within the service. They were responsive and showed accountability to wanting to make the required improvements to remedy the shortfalls we had identified during our inspection.

We found the service met the requirements for good in three areas and requires improvement in two other areas. 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 (inspection report published on 21 January 2015).

Why we inspected

This was a planned inspection based on the service's previous rating.

Enforcement

We have identified breaches in relation to ensuring risks to people's welfare and safety were identified and acted upon as well as ensuring medicine management was in place to keep people safe 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 for 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.