Tudor Cottage

Tudor Cottage is registered to provide accommodation and nursing and personal care for up to 19 people. The service is intended for older people, who may also have a physical disability, mental health needs or a dementia type illness. The service is in a large period house located in the market town of Axminster in East Devon. The home is within walking distance of Axminster town centre, local church and post office.

This inspection took place on 7 and 13 February 2020, the first day was unannounced. There were 16 people living at the service at the time of the inspection. One of these people were staying at the home for a period of respite care.

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

People were cared for by staff who knew how to keep them safe and protect them from avoidable harm. Staff were kind and compassionate and respected people’s privacy and dignity. The atmosphere within the home was friendly and welcoming and staff were warm and considerate towards the people they cared for.

There were sufficient staff available to meet people's needs and people told us when they needed assistance, staff responded promptly. The provider was monitoring the staff level at night to ensure it met people’s needs.

People’s medicines were safely managed, and incidents and accidents were investigated, and actions were taken to prevent recurrence. The home was clean, and staff followed infection control and prevention procedures.

The service continued to be effective. People's needs were assessed before they came to the home. At the time of the inspection the service was changing to a new electronic care record system. This meant some information about people’s care was on the old paper system and other information was on the new system. On the first day of the inspection, we found some people’s risk assessments and care plans lacked detailed information to guide staff about some safety aspects. We highlighted this to the provider. By the second day of the inspection, these risk assessments and care plans had been updated and were well understood by staff. The provider had arranged additional help to complete updating all people’s care records in the new format.

Staff were well trained and knowledgeable about people's care and support needs. People were provided with a nutritious and varied diet and they were positive about the quality and choice of food offered.

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 supported this practice. When people were unable to make decisions about their care and support, the principles of the Mental Capacity Act (2005) were followed.

Staff were responsive to people's individual needs and had an in-depth knowledge about each individual. Staff offered people choices on an ongoing basis.

People had access to a range of activities and entertainment that they enjoyed. People's views and concerns were listened to and action was taken to improve the service as a result.

The service continued to be well led and benefitted from clear and consistent leadership. The management team were praised by staff, for their supportive approach.

Systems were in place to monitor the quality of care provided and continuously improve the service.

Why we inspected

This comprehensive inspection was brought forward two months because of concerns raised with the Care Quality Commission (CQC) and the local authority safeguarding team about people’s care, staffing and care practice, medicines management, documentation and leadership at the home. We made the decision to inspect earlier than planned so we could examine those risks as part of the inspection.

We also participated in a multiagency meeting with the provider and local health and social care professionals to discuss the concerns raised. This included identifying and agreeing further actions needed to support people living at the home and staff caring for them.

The last rating for this service was Good (published 17 August 2017).

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This unannounced comprehensive inspection took place on 17 and 18 August 2017. This inspection was to follow up to see whether improvements had been made and ensure the provider had maintained standards in other areas.

Previously on 7 February 2017, in response to concerns raised, we inspected the service and looked at the safe and well-led domains. At that inspection we found some people’s risk assessments did not identify all risks, or adequately assess and manage how people’s individual behaviours might impact on their safety and wellbeing or safety of others and staff. Further improvements were also needed in record keeping and in team working. Although no breaches of regulations were found, both domains were rated as requires improvement.

Prior to that on the 17 and 18 December 2015 we carried out a comprehensive inspection. At that inspection, the service was rated ‘Good’ overall and in each of the safe, effective, caring, responsive and well led domains.

The service has 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 service is run.

The service had worked with the local authority quality improvement team to make the required improvements.

People's risk assessments were more comprehensive with actions taken to reduce the risks as much as possible. Staff demonstrated a good awareness of each person's safety and how to minimise risks for them. Accidents and incidents were reported and included measures to continually improve practice and reduce the risks of recurrence. Staff understood the signs of abuse and knew how to report concerns, including reporting to external agencies. They had completed safeguarding training and had regular updates. A detailed recruitment process was in place to ensure people were cared for by suitable staff. People received their medicines safely and on time from staff that were trained and assessed to manage medicines safely.

People received a good standard of care because the management team set high expectations of the standards of care expected. There was a clear management structure in place, staff understood their roles and responsibilities and felt valued for their contribution. Staff had the knowledge and skills needed to carry out their role.

Staff developed positive, kind and compassionate relationships with people. People appeared happy and content in their surroundings and were relaxed and comfortable with staff who were attuned to their needs. The service had enough staff to support people's care flexibly around their wishes and preferences. People's care was individualised, staff knew people well and treated them with dignity and respect. Significant improvements had been made in the variety of group and personalised activities for people living at the home with an increased focus on social contact and companionship.

People experienced effective care that promoted their health and wellbeing. People praised the quality of food and were supported to improve their health through good nutrition. People had access to healthcare services, staff recognised when a person's health deteriorated and sought medical advice promptly.

People's rights and choices were promoted and respected. Staff understood the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards; they involved the person, family members and other professionals in 'best interest' decision making.

Care records had improved and further improvements were being made. People knew how to raise concerns and complaints, and were provided with information about how to do so. Any concerns raised were robustly dealt and further improvements made.

People and relatives were happy with the service provided at Tudor Cottage. The culture of the home was open, friendly and welcoming. Care was person centred, staff knew about each person and their lives before they came to live at the home. They understood people's needs well and cared for them as individuals.

We previously carried out a comprehensive inspection at the service on the 17 and 18 December 2015. At that inspection, we found no breaches of regulations. The service was rated ‘Good’ overall and in each of the safe, effective, caring, responsive and well led domains. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Tudor Cottage on our website at www.cqc.org.uk

Tudor Cottage is registered to provide accommodation with personal care for up to 19 older people, who have become frail, are living with dementia or who require respite or palliative care.

The service has 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 service is run.

On 30 January 2017, concerns were first raised to the Care Quality Commission (CQC). They included allegations about poor standards of practice, about attitudes of three staff working at the home and about an agency worker who had previously worked at the home. The person who had contacted us was concerned about the safety and wellbeing of eight people in particular. We raised a safeguarding alert to the local authority safeguarding team about those people. We also contacted the district nursing team who visited the home regularly for feedback, who had no current concerns about the service. Following this, a second person contacted CQC and the local authority safeguarding team with similar concerns. As the concerns included allegations the manager failed to take appropriate action in response to some specific concerns, the safeguarding team contacted the provider and asked them to investigate the concerns.

Most people said they were happy living at the home and felt safe living there and we had no concerns about staff interactions with people when we visited. However, one person we spoke with raised some concerns. The person had told the provider about this, which they confirmed they were aware of.

People knew how to raise concerns and were confident any concerns would be listened and responded to. Staff were knowledgeable about people’s care needs, although some areas for improvement were identified in relation to one person’s risk assessments and care plans. Staff were aware of signs of abuse and knew how to report concerns.

The provider undertook a detailed investigation and provided a written report to the CQC and the local authority safeguarding team. They interviewed people who lived at the home and some relatives and staff working at the home including the registered manager. The provider’s report showed the investigation was hampered because there was a lack of information about dates and time certain incidents were alleged to have taken place, and a lack of records related to them.

The provider’s report showed most people were happy living at the home and had no major concerns. Most staff were also happy working at the home and felt well supported. Most of the allegations could not be proven. Some concerns about an agency worker who previously worked at the home were upheld and had already been reported to the agency that employed them for further action. The report also confirmed a person did not receive breakfast on one occasion. It also identified some misunderstandings and miscommunication within the staff team about practice, which the provider planned to address.

The report showed the provider took the concerns seriously and was committed to learning lessons and making further improvements in response.They planned to meet with staff to discuss the findings of their investigation, and remind them about professional boundaries. They also planned to reiterate the home’s safeguarding and whistleblowing policies, through which concerns should be raised. The provider undertook to increase observations of staff practice including their communication and interactions with people. They also planned to offer further staff training and supervision where needed. Other planned improvements included changes to people’s individual care records and record keeping systems and strengthening monitoring arrangements.

The local authority safeguarding team have arranged for care managers to visit the home to review the care of some people who live there. Representatives of the local authority quality monitoring team will visit the home and work with staff to support the improvements needed. The local authority safeguarding team confirmed they were satisfied with the actions taken by the provider and have closed the safeguarding investigation.

Although no breaches of regulations were found at this inspection, some areas for improvement were identified. We will carry out a comprehensive inspection at this home within six months to check the improvements have been made and to check on the safety and quality of care people receive.

All of the relatives told us that they were satisfied with the care and support their relative received. One told us 'They're really good in here.' Another relative said 'It's really good here, we are really pleased. It has a very good reputation locally.'

We found that people had comprehensive care plan files, which contained lots of information on how people wanted to be supported, and what they were able to contribute themselves. This meant support staff could be clear about what type of support a person needed, their choices and preferences, and which parts of tasks they were able to do for themselves.

The home is an older listed building and in places had low ceilings and numerous corridors to rooms. We saw that in places protective foam had been fitted to particularly low door frames and warning signs were on display. One person and a relative told us they sometimes had difficulty with the uneven floors; however two relatives told us that they felt the character of the home made it feel like 'coming to someone's house' and that their relative liked it and found it 'very cosy.'

Whilst at the service we heard and saw staff talking with people and offering them choice and support in a respectful and positive way.

Staff and representatives said that they knew how to raise a concern or make a complaint. There were policies and procedures in place providing guidance and all staff had received safeguarding training which were identified on the training matrix.

Staff told us they were supported by management and that they received regular training. We saw that staff were supervised regularly and were appraised annually. The quality of the service was monitored at local and provider level through regular spot checks. People who used the service and representatives were provided with the opportunity to give feedback regarding the running of the service.