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Inspection Summary

Overall summary & rating


Updated 25 March 2020

About the service

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 need

Inspection areas



Updated 25 March 2020

The service was safe.

Details are in our safe findings below.



Updated 25 March 2020

The service was effective.

Details are in our effective findings below.



Updated 25 March 2020

The service was caring.

Details are in our caring findings below



Updated 25 March 2020

The service was responsive.

Details are in our responsive findings below.



Updated 25 March 2020

The service was well-led.

Details are in our well-Led findings below