Archived: Tudor Care Home

Updated 26 October 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This was a comprehensive inspection completed by one inspector and an expert by experience on 12 September 2017. It was unannounced. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before our inspection we reviewed the Provider information return (PIR). The PIR is a form that asks the provider to give some key information about what the service does well and improvements they plan to make. We reviewed information that we held about the service such as notifications, which are events which happened in the service that the provider is required to tell us about. We also looked at information that had been sent to us by other agencies. This included the local authority who commissioned services from the provider. We also sought feedback from Healthwatch Leicestershire (the consumer champion for health and social care).

During our inspection we spoke with two people who used the service and three relatives. Some people had limited verbal communication but were able to tell us what they thought. We observed interaction between staff and people who used the service during our visit. We also spoke with three members of staff, the registered manager and a visiting health professional.

We looked at records and charts relating to two people and four staff recruitment records. We looked at other information related to the running of and the quality of the service. This included quality assurance audits, training information for care staff, staff duty rotas, meeting minutes and arrangements for managing complaints.

Updated 26 October 2017

We carried out this unannounced inspection on 12 September 2017.

Tudor Care Home is registered to provide accommodation and care for up to ten older people who are living with Dementia or who have a physical disability. The home is located on two floors with a stair lift to access the first floor. There was a communal lounge, kitchen and dining room where people could spend their time. At the time of the inspection there were nine people using the service.

The service had 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.

People were protected from the risk of harm at the service because staff knew their responsibilities to keep people safe from avoidable harm and abuse. Staff knew how to report any concerns they had about people’s welfare.

There were effective systems in place to manage risks and this helped staff to know how to support people safely. Where risks had been identified, measures to reduce these were in place.

There were enough staff to meet people’s needs. The provider had safe recruitment practices. Staff had been checked for their suitability before they started their employment.

People’s equipment was regularly checked and there were plans to keep people safe during significant events such as a fire. The building was well maintained and kept in a safe condition. Evacuation plans had been written for each person, to help support them safely in the event of an emergency.

People’s medicines were handled safely and were given to them in accordance with their prescriptions. Staff had been trained to administer medicines and had been assessed for their competency to do this. Liquid medicines were not always dated when they were opened. Staff had not always signed when they had given a person their medicine. There were processes in place to ensure medicines had been given.

Staff received appropriate support through a structured induction, support and guidance. There was an on-going training programme to ensure staff had the skills and up to date knowledge to meet people’s needs.

People were supported to maintain good health and nutrition. People had access to healthcare services. Follow up actions from health appointments were not always recorded.

People were supported to make their own decisions. Staff and managers had an understanding of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Assessments of mental capacity had usually been completed. Staff sought people’s consent before delivering their support.

People developed positive relationships with staff who were caring and treated them with respect, kindness and compassion.

People received care and support that was responsive to their needs and preferences. Care plans provided information about people so staff knew what they liked and enjoyed.

People were encouraged to maintain and develop their independence. People took part in activities that they enjoyed.

People and their relatives knew how to make a complaint. The provider had implemented effective systems to manage any complaints they may receive.

Systems were in place which assessed and monitored the quality of the service and identified areas for improvement. These had not always been completed at the required frequency.

Policies and procedures were in place and gave staff guidance on their role. These had not always been updated to reflect current legislation.

People and staff felt the service was well managed. The service was led by a registered manager who understood most of their responsibilities under the Care Quality Commission (Registration) Regulations 2009. Staff felt supported by the registered manager.

People had been asked for feedback on the quality of the service they received.