Archived: The Tudors Care Home

Updated 18 February 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check 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 inspection took place on 28 November and 02 December 2014 and was unannounced.

This inspection was completed by two inspectors, a pharmacist inspector and an expert by experience. An expert by experience is a person who has personal experience of caring for someone who uses this type of care service. Before the inspection, we asked the provider to complete and return a provider information return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and any improvements they plan to make. The provider completed and returned the PIR form to us and we used this information as part of our inspection planning.

We looked at other information that we held about the service including information received and notifications. Notifications are information on important events that happen in the home that the provider is required to notify us about by law. We also looked at the local authority reports from their recent visits to the service.

We observed how the staff interacted with people who lived in the home. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with five people who used the service and six relatives. We also spoke with the acting regional manager, manager, deputy manager, four care staff, chef, laundry person, two domestic workers, maintenance and administrator. We received feedback about the service from a community nurse and a social worker who were visiting the home on the day of our inspection.

As part of this inspection we looked at five people’s care records and records of staff induction, training and supervisions. We looked at other documentation such as quality monitoring information, complaints and compliments, staffing rotas, medication administration records and the homes business contingency plan.

Updated 18 February 2015

This unannounced inspection was carried out on 28 November 2014 and 02 December 2014. The previous inspection took place on 19 and 20 June 2014, during which we found a number of breaches of the regulations. These breaches were in regulation 15, safety and suitability of premises, regulation 12, cleanliness and infection control, regulation 13, management of medicines and regulation 10, assessing and monitoring the quality of service provision. We asked the provider to make the improvements required. The provider told us that these improvements would be completed by 30 September 2014.

We found that the provider had made the required improvements except for regulation 13 management of medicines, where we found a continued breach.

The Tudors Care Home is a care home for up to 44 older people. It is registered to provide personal care but does not provide nursing care. The home offers accommodation over one floor in the unit for people living with dementia and over two floors in the residential unit. Each unit has single occupancy bedrooms and there are internal and external communal areas, including lounge/dining areas and a garden for people and their visitors to use. There were 41 people living in the home at the time of our visit.

At the time of this inspection there was not a registered manager in place. 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 Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and report on what we find. We found that there was a lack of formal systems in place to assess people’s capacity for decision making. This meant that people’s rights were not being protected as no applications had been made to the authorising agencies for people who needed these safeguards.

We saw that people who lived in the home were assisted by staff in a respectful way that also supported their safety. People had care and support plans in place which documented their needs. These plans gave staff guidance on any assistance a person needed as well as their individual choices and preferences.

Risks to people were identified and plans put into place by staff to minimise these risks and enable people to live as safe and independent life as possible. However, not all risk assessments were up to date.

The service had made improvements since the previous inspection as there were now better arrangements in place for the management and administration of people’s prescribed medication. However, improvements were still required as records which documented the time medication was administered was not always completed which meant that there was a risk of medication being given too soon after the previous dose or too far apart. We also found that there were no formal capacity assessments in place for people given their medication disguised in their food and/or drink.

We observed that staff cared for people in a caring and warm manner. We saw staff using distraction as a technique to calm people down when they were becoming increasingly anxious.

Staff were trained to provide safe and effective care which met people’s individual support needs. They understood their role and responsibilities and were supported by the manager to maintain their knowledge and skills by supervision, appraisals and training. Staff told us that there was an open culture within the home and this was confirmed by our observations during our visit.

Relatives we spoke with told us that they were able to raise any concerns or suggestions they might have with the staff or manager and that action had been taken when they had raised a concern.

There were quality monitoring systems in place to identify areas for improvement. We saw that there were actions plans/ work in progress in place to implement the improvements required.

We found 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.