Archived: Tudor Lodge

This service was last inspected on 3 December 2014 under previous methodology and at that time the provider was found to have addressed previous noncompliance and no breaches of regulations were identified.

There was a registered manager in post. A registered manager is a person who is 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 told us they were happy living at the service. People’s relatives spoke positively about the quality and delivery of care provided by staff to their family members, but expressed concerns that staffing levels meant staff could not always give people the time they needed; staff said they felt rushed all the time. We observed that for the needs and dependency of the people being supported there were not enough staff available at some busier times of the day and also during the night, when a number of people were up. Recruitment procedures and checks of new staff were made but this needed improvement to ensure these were carried out thoroughly and in line with regulatory requirements.

The risk assessment framework used needed expanding to ensure all potential risks people may be subject to were assessed and measures implemented to reduce risk of harm occurring.

Care plans were individualised but did not always reflect in depth strategies used to manage behaviour or support in respect of specific health conditions. Quality audits were in place but not always carried out robustly or evidenced clearly actions taken to provide assurance that the service was meeting standards. The Care Quality Commission was not routinely informed as required of deaths of people at the service.

Professionals we spoke with during and after the inspection spoke positively about the improved communication with them from staff and good working relationships that the registered manager was developing with them.

Visual checks that fire extinguishers and emergency lighting was in working order were not routinely undertaken each month. Staff were not attending the minimum number of fire drills annually and had not trained in the use of some evacuation methods contained in people’s personal evacuation plans.

People enjoyed the activities provided for them and although they were consulted through meetings and questionnaires about what else they might want to do, the type of activities available were not suitable for everyone and we have recommended the registered manager sources appropriate training for the activities organiser to make activity sessions more appropriate to the needs of people.

Staff received supervision and appraisal of their work performance. They had opportunities to meet and felt able to raise issues individually or within staff meetings, staff said communication was good and they felt part of a team and enjoyed their work but did not always feel their views were valued or listened to by some of their line managers.

There was a high level of accidents occurring. Staff took appropriate action to support people when accidents occurred and sought medical advice if necessary, the manager analysed these for trends but we have suggested additional analysis to help understand more about why they were occurring.

Staff treated people respectfully, showed kindness and patience and we saw many examples of positive interactions from staff towards people. Staff placed people at the centre of the support they provided and delivered this in a personalised way to meet individual needs.

People and their relatives told us they felt informed by the staff and that communication was good. They were asked for their views and people felt able to voice their comments openly in user meetings. People ate a varied diet that took account of their preferences. Peoples health needs were monitored and they were supported to access healthcare appointments.

Staff knew how to protect people from abuse. The premises were clean and well maintained and servicing checks were in place. New staff received appropriate induction and all staff completed a regular programme of training. Staff understood and worked to the principles of the Mental Capacity Act 2005, although improvements in recording of some decisions was needed.

People’s privacy was respected. Staff supported people to maintain links with their relatives and representatives, and relatives said they were kept informed and consulted about their relatives care needs. People and relatives understood the complaints procedure and felt confident any issues if they had any would be addressed immediately.

We have made one recommendation:

We recommend that the Registered Manager enables the activities organiser to access an activities training course from a competent and recognised source that promotes activities for people with dementia type conditions using the latest best practice.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

During this visit we looked at the systems in place for the ordering, receipt, storage, administration and disposal of medicines and the improvements the provider had told us about. From our discussion with the registered manager, a review of records and our inspection of medicine storage. We were satisfied that there were appropriate and safe systems in place for the management of medicines, and that previous shortfalls addressed within the providers action plan had been implemented and were being sustained.

We re-inspected the home on 18 September 2014 to assess whether all areas of concern had been addressed. Our inspection was unannounced and the inspection team included two inspectors with backgrounds and experience of adult social care and an expert by experience. During this inspection we re-visited bedroom and shared space areas, and met and spoke with 18 people living in the home and one of their relatives. We viewed care and management records and spoke with ten staff including care staff and members of the housekeeping staff. This included discussions with the registered manager and two provider representatives.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

Staff told us that they could now provide a good level of support to people since the addition of new staff onto the day time shifts. This needed to be kept under review to ensure that the dependency levels of people during day time and night shifts could be appropriately met.

We spoke with people who told us they were happy living in the home. We sampled care documentation and found this to be reflective of the current needs of the people concerned, and this was kept under regular review by staff. People's capacity to make their own decisions around their care was considered and where necessary their families or other representatives were involved in decision making. Staff told us that people were consulted about their care plan and where able to sign their consent to their plan of care. Activities were provided but more needed to be done to tailor these to the specific needs of those people with dementia, and to enable people to have some opportunities to go out into the community.

We spoke with staff about how improvements made had impacted on their delivery of care to people. They told us that they now had more time to spend with people and this enabled them to look at everyone's needs not just those who needed immediate support.

Improvements to the number of cleaning staff and the scheduling of cleaning across the day had been implemented and those people who had higher dependency needs in regard to maintaining a safe and clean environment were now given additional support. This showed a commitment by the provider to ensure infection control standards were effective and meeting the needs of people in the home.

The home had made improvements to the administration of medicines and we saw some good practice and records showed a range of audits in place to ensure medicines were handled safely. Although the provider had made the improvements we had asked in some areas, our inspection highlighted two new areas of concern which we brought to the attention of the provider. This was a breach of regulation 13 of the Regulated Activities regulations 2010, and the action we have asked the provider to take is at the end of the report.

Is the service effective?

Staff told us that people were now given greater choice around meals and an open buffet arrangement was in place for breakfast meals. Cooking staff had received additional training to help provide more appropriate meals for people with dementia and this was an area for continued improvement.

Staff spoke about sitting down with people to talk about their care and support needs, and records showed that mental capacity assessments were routinely conducted in regard to everyday support and care decisions. The manager and staff showed an understanding of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) legislation. (This protects people from having decisions taken for them without consultation and ensures that care and support provided is not overly restrictive). The manager was able to demonstrate this was being implemented on a priority basis for people in the home who were most affected.

Staff were receiving the appropriate essential training and new staff were receiving induction into their role.

Is the service caring?

Some people we spoke with did not want to be in a care home but were unable to manage on their own any more and could place themselves and others at risk. The need for them to be in the home influenced their views about living there. However other people had insight into why they were in the home and were able to give an objective view about living there, and for most people we spoke with this was positive. They said they found staff to be kind and friendly. A relative told us 'I think this is one of the best homes in this area regarding care that residents receive in spite of the age of the building. My mother is fortunate in the fact that she is on the ground floor and can go to her room when she wishes'.

We spoke with a mix of established and new staff who showed a good level of understanding of individual people's needs, spoke respectfully and kindly about people and showed a commitment to the continued improvement of the service.

Is the service responsive?

The home provided people with daily and quarterly newsletters. Surveys were also conducted annually to seek the views of people and their relatives. Resident meetings were held and people were able to raise issues about the things that concerned them.

Staff had raised money to help fund some activity resources and staff said they were able to spend more time with people. There was an activities coordinator who provided activities that people said they wanted, however activities were not available at key times of mornings and weekends and were not always suited to the needs of people with dementia. The garden area was not easily accessible for people to spend time in. However, the manager and staff showed that they had taken action to reduce the isolation of some people in the home. The provision of new equipment had enabled one person previously confined to bed to visit the lounge and participate in the activities happening there and eat their meals with others. Referral to the mental health team for other people had helped develop strategies for managing some people's isolation and providing them with appropriate outlets.

Is the service well-led?

A clearer management structure had been developed which staff were aware of. The effectiveness of audits conducted by the manager and the operational manager had been reviewed and included medicine, infection control, and environmental audits. These were more effective and showed where shortfalls had been highlighted and actions taken as a result. Staff told us they had regular staff meetings which they now valued and felt empowered to raise issues of concern, and felt they were listened to. Staff felt there had been a change in the overall atmosphere of the home and that there was a more open culture between management and staff. Although communication was still an area for improvement, staff commented positively about the change to the home and now felt it was a place where they wanted to work.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We found that staff demonstrated a good understanding of what support they needed to offer people, and care plans were in place. However, changes in care needs were not accurately reflected in care records, and some people's needs were not met. This meant that staff were not always providing an appropriate standard of care. Some improvements had been made to address shortfalls in infection control standards but these were not wholly effective and we found examples of poor practice and cleaning. The management of medicines was not safe and could place people at risk.

Is the service effective?

From records viewed we saw that people's capacity to make everyday decisions for themselves was assessed. People or their relatives were asked to consent to the plan of support developed for them. Staff did not always have the skills and knowledge to provide appropriate care to people with specific needs. The majority of people received a nutritious balanced diet that took account of their preferences, but the nutritional needs of people that required softer diets were not being met.

Is the service caring?

When we spoke with people many of them said that they liked living at the home and found the staff were nice and friendly. Observations of staff assisting people showed them to demonstrate a warm and caring approach towards people. Relatives also expressed confidence in the caring attitudes and abilities of staff. However, some people we spoke with raised concerns about the attitudes of some staff in their treatment either of themselves or of less able people. We have passed these concerns to social services to investigate.

Is the service responsive?

The service provided people in the home with a newsletter and also undertook surveys to gain feedback from them and their relatives about the quality of care they received. There was a programme of activities but this did not take account of the needs of people with dementia or those who were isolated in their rooms.

Is the service well-led?

There was a management structure in place and clear lines of accountability. A programme of audits was in place to provide information to the manager and provider regarding the quality of care delivered. These included medicine, infection control, and environmental audits. These were ineffective as they had not highlighted many of the shortfalls we found, showing that they had been missed during auditing procedures. There was no clear evidence that the home was learning from incidents, accidents and complaints. Staff told us they had received regular staff meetings and had one to one time with their manager, but saw little value in the staff meetings they attended. The culture within the home did not foster a sense of openness and transparency that enabled staff or the people living there to either raise concerns or feel that they were handled appropriately when they did so.

People had their needs assessed, and responded to. This included routine health appointments, and contacting their GP when necessary.

The home looked clean and tidy, but there were gaps in how the service managed infection control which might put people at risk.

Equipment in the home, such as hoists and stairlifts, were serviced and maintained.

The necessary recruitment checks were carried out of staff before they started working in the service.

Staff received adequate supervision and training to provide care to people using the service.

People had their comments and complaints listened to and acted upon. The people using the service, or their relatives, told us they found the manager 'very approachable' and could talk to any of the staff. We were told 'they're approachable if there's a problem' and 'they do everything they can to sort it out.'

During this inspection we primarily looked at processes that related to the management of medicines and how the quality of the service provided to people was assessed and monitored.

People we spoke with were happy living at Tudor Lodge and spoke positively about the staff. Comments people made included 'I am relaxed living here, staff are friendly and approachable' and 'When staff support me, they explain what they are doing'.

People told us they were confident with staff supporting them to take their medicines. People said that they received their medicine when they were supposed to and knew what the medicine was for.

People said they had opportunities to offer their views and make suggestions about quality of the service they received. They could do so at regular meetings and in addition, the service had recently completed a survey of satisfaction for people who lived at there, their families and representatives.

All of the people we spoke with told us that they were satisfied with the care and support provided. One person commented 'I can't fault the staff, they are all lovely'. We saw that staff were supportive and considerate of people's different needs and how to communicate with them. People were offered choices and we saw that their dignity and independence was respected.