Tudor Lodge

Tudor Lodge is a residential care home providing care and accommodation for up to 44 older people living with dementia, in one large adapted building. At the time of our inspection there were 40 people using the service.

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

People appeared to be happy and relaxed in the company of staff. People told us they felt safe with staff. Relatives told us they thought their loved ones were safe and well looked after.

Potential risks to people’s health and welfare had not been consistently assessed, there was not always detailed guidance for staff to mitigate risks. Accidents and incidents had been recorded and analysed, however, there was not consistent records of the action taken to reduce the risk of them happening again.

Medication was not always managed safely, people had not always received their medicines as prescribed. Staff were recruited safely, there were enough staff to meet people’s needs. However, there was not a consistent system to calculate the number of staff required when people’s needs changed.

Audits had been completed to check the quality of the service, however, these had not been effective in identifying extent of the shortfalls found at this inspection. There had not been a comprehensive action plan in place to rectify any shortfalls found.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There were systems in place to protect people from discrimination and abuse. The registered manager had reported incidents to the local authority as required and worked with them to reduce the risk of them happening again.

Relatives told us they were confident to discuss any concerns with the registered manager and had been kept informed of incidents and their relatives health. Relatives visited when they wanted and were supported to take people out. Staff were wearing personal protective equipment in line with government guidance.

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

Rating at last inspection

The last rating for this service was Good (published 31 December 2020).

Why we inspected

We received concerns in relation to management of risk and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Tudor Lodge on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to risk management, medicines and governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Tudor Lodge is a residential care home. It provides care and accommodation for up to 44 people aged 65 and over. At the time of inspection 36 people were living in the service.

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

We found there was a calm happy atmosphere in the service and people looked to be well cared for. Staff were observed to be kind and caring when supporting and assisting people.

Due to concerns around COVID 19 infection we kept our contact with people to a minimum so as not to place them at risk. We did observe people and saw that they were content and able to move freely around communal areas of the service, sometimes gathering in little groups together or dancing to the music. People were kept entertained by an in-house activities’ organiser. We spoke with five relatives of people living in the service, they spoke positively about the care provided and told us that they were kept well informed about their relative’s wellbeing. They understood the homes arrangements for preventing spread of COVID 19 in the home and how this impacted on their visits.

Accidents and incidents were monitored and responded to appropriately. Learning from when things went wrong was used to inform staff practice and shared with them in staff meetings.

There were enough staff to support people receiving the service, and there was a safe system for their recruitment. Staff received appropriate training to ensure they understood how to keep people safe. Risks were appropriately assessed and managed. Staff had received additional infection control training to support their understanding of the COVID 19 pandemic. They were provided with personal protective equipment and wore this throughout their shifts to keep people safe and minimise risks of infection.

Medication was managed safely with improvements in the administration of as and when required medicines and daily auditing of medicines administered and recorded. This ensured people were receiving the right medicine when they needed it.

The Registered manager undertook regular audits of the service to assess service quality and assure themselves people were safe and standards maintained. They worked in conjunction with the operational manager to identify areas for improvement. We signposted them around the need to ensure changes for some people were accurately documented in care records. However, the overall impact to the people in question was minimal, having been reduced by staff knowledge and awareness of these changes. We did note minor improvements to the standard of cleaning and discussed this with the provider who was able to provide assurance this had already been identified and was being acted upon.

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

Rating at last inspection (and update) The last rating for this service was requires improvement (published 17 May 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found

improvements had been made and the provider is no longer in breach of regulations.

Why we inspected

We undertook this focused inspection to check specific concerns we had about the governance of this service and to check that their action plan and to confirm they now met legal requirements and no other risks were identified. This report only covers our findings in relation to the Key Questions Safe and Well-Led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has now changed from Requires improvement to Good. This is based on the findings at this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Tudor Lodge on our website at www.cqc.org.uk.

Follow up

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

People’s experience of using this service:

At our last inspection in November 2017 we identified that some people did not always receive the support they needed at mealtimes; we observed that people’s privacy and dignity was not always upheld; risks around some people’s safety had not been assessed. Records were not always accurate or accessible and systems for assessing and monitoring service quality were not robust. The provider told us what action they would take to improve this.

At this inspection we found that there had been progress and improvement in many areas and most of the previous breaches in regulation met. We found however that medicines were not being managed safely and have issued a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Although strengthened the system to assess, monitor and improve the service and improvements to the accuracy and completion of records had not fully met the previous breach Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 has not been fully met and further improvements are needed

Since the last inspection there was a new registered manager, she had worked hard to change the culture within the service and address previous shortfalls, as a consequence there had been a complete turnover of staff. This was enabling the registered manager to develop a new team and culture within the service. Staff thought communication was good between staff and that there were good working relationships. The provider acknowledged further work was needed and had already identified further improvements to be made from within their own service development action plans. This included for example team building, record keeping, and improving the type and range of activities and stimulation for people in the service. Overall staff told us that they enjoyed where they worked and were committed to providing people with good quality care.

People and relatives spoke positively about service quality. People told us that they felt safe and well cared for. Relatives felt reassured that their relative was living in a safe place where their needs were taken care of. Relatives told us that they had found communication from staff to be good and the registered manager approachable. People and relatives told us that staff were caring and took time to get to know people well. People and relatives told us that they had no concerns but felt able to raise them if they did and were confident these would be acted upon.

We observed that there were enough staff to support people’s needs during the day, the provider agreed to relook at morning availability of staff which had been highlighted by some staff as a particularly busy time.

A full range of checks were made of new staff to help ensure people were supported by suitable staff.

Staff were provided with an appropriate programme of training to understand and support people’s individual needs. They demonstrated a detailed knowledge of people and their routines and preferences.

People lived in a safe well-maintained environment where equipment was routinely serviced and checked that in was in safe working order.

Improvement recommendations made by the fire service were being addressed to ensure they met the required standard of fire safety.

Peoples health needs were supported. Health professionals visiting to provide routine health care support raised no concerns about the appropriateness of referrals to their service; they said staff followed advice and guidance appropriately in support of people’s health needs.

Staff felt confident of raising issues with senior staff and felt supported, they had opportunities to express their views in staff meetings. A one to one supervision and appraisal schedule was commencing.

People and relatives were surveyed for their views. Their feedback informed the continuous improvement and development of the service.

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

Rating at last inspection: At our last inspection this service was rated requires improvement (Published 21 February 2018 ) This will be the second time the service has been rated requires improvement.

Why we inspected: This inspection was part of our scheduled plan of visiting services based on their previous rating to check the safety and quality of care people received.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned in line with our inspection schedule.

At the last inspection on 12 October 2017 the service was overall rated as Good.

At this inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also made two recommendations in relation to good practice. You can see what action we told the provider to take at the back of the full version of this report.

Tudor Lodge is a ‘care home’. People in this care home receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Tudor Lodge accommodates up to 44 older people some of whom are living with dementia. There were 40 people living at the service when we inspected.

The service was run by a registered manager and they were present on the days of our visit. ‘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 and their relatives told us staff were kind and caring and made people feel safe. They said staff had the necessary skills to respond to people’s needs, monitored their health and that people enjoyed their meals.

Staff sought and received people's consent to the support they provided and in line with the principles of the Mental Capacity Act 2005. CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The service had made DoLS applications, to ensure that people were only deprived of their liberty, when it had been assessed as lawful to do so

People’s needs were assessed and a plan of care was developed which included their choices and preferences, but was not always person centred and accurate.

There was inconsistency in staff practice which meant that people’s dignity was not always respected.

People’s health needs were assessed and monitored and the service worked in partnership with healthcare professionals to ensure people received appropriate care and treatment. However, there were examples where the provider had not effectively managed and responded to risk.

Medicines were managed safely and people received them as prescribed.

Recruitment practices were robust in ensuring only suitable staff were employed at the service.

Staff training was on-going and plans were in place to ensure they received relevant training for their role. Staff felt well supported both informally and through formal processes such as staff meetings and supervisions.

Management systems were in use to minimise the risks from the spread of infection and keep the service clean, although records did not always support this.

We have made recommendations about the deployment of staff to ensure they are available in suitable numbers to meet the needs of people living with dementia; adaptation to the environment to support independence of people living with dementia; and promoting activities and stimulation to meet the needs of all the people at the service.

Systems to monitor the quality of care were not effective. Potential risks were not always accurately monitored and recorded and records were not always accurate which could result in people receiving inappropriate staff support.

The views of people and their relatives were sought through meetings and an annual survey.

Tudor Lodge is a large detached house in a quiet residential area. It provides care and support for up to 44 older people some of whom are living with dementia. There were 38 people living at the service when we inspected.

The service had a registered manager in post. 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. This is the first inspection since a change to the providers registration in October 2016.

People, relatives and health professionals told us that people were safe at the service. People were supported by staff who had received safeguarding training and understood their responsibilities in keeping people safe from harm. The registered manager had contacted the local authority safeguarding team when required and had taken action to keep people safe. Risks to people were identified and assessed. Plans were put in place to minimise risks and gave staff the guidance they needed to mitigate risks. People’s medicines were managed by trained staff and people were supported to be involved as they wished. Some people at the service chose to manage their own medicines and they were supported to do this safely.

People were supported by staff who told us they had the training and support they required to meet people’s needs. There was a schedule of training in place which included competency assessments. Some staff had begun additional training to become a ‘champion’ in areas such as dignity or dementia. Health professionals told us the staff were “on the ball and knew how to care for the people who live at the service.” Staff had regular meetings and one to one supervisions with their line manager. The registered manager used a dependency tool to identify how many staff were needed on duty. There were enough staff to meet people’s needs and people told us, “There is always someone nearby if you need help.” Staff were recruited safely, checks were carried out to ensure they were suitable for their role before they began working at the service.

People are 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. Staff asked for people’s consent before giving support and explained to people what was happening. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. The registered manager had applied for DoLS when required.

People were supported by staff who knew them well and treated them with dignity and respect. Staff treated people as individuals and adapted their interactions to meet each person’s needs and preferences. Staff told us about people’s lives before they lived at the service and the activities they enjoyed the most. People’s care plans were person centred and gave staff the guidance they needed to know what people could do for themselves and when they needed support. Care plans included life histories and small details about people’s preferences, for example how they like their room at night or their favourite fragrance. People and their relatives told us they were involved in planning and reviewing their care on a regular basis. People were supported to remain as independent as possible. On the day of the inspection several people went out independently.

People took part in range of activities based on their interests and hobbies and there was an activities co-ordinator at the service. One person said, “There is always something going on if you want to join in.” Activities were displayed in an accessible format using pictures. There was also a pictorial menu board showing people the food on offer in the dining room.

People told us the food was good and that there was always a choice of meals. People chose where they ate their meals and lunchtime was a social event with people chatting as they ate. When people had specific dietary requirements these were catered for and people had been referred to dieticians when they were at risk of losing weight. Health professionals told us, “They are very responsive here; they always notice quickly if people are unwell and ask for support.” When people were unwell or were living with a health condition such as diabetes, staff supported them to book and attend any health appointments.

The registered manager and staff told us the focus of the service was to give people care and support in the way they preferred and to keep improving the quality of care offered. People, staff relatives and health professionals told us the registered manager and provider were accessible and approachable. One person said, “If I ask the manager for anything I know they will do it.”

Risks to the environment were identified and assessed, plans were put in place to minimise risks in the way that was least restrictive to people. Regular fire drills were carried out and weekly fire checks were carried out. People had personal emergency evacuation plans which detailed the support people would need emotionally and physically to leave the building in the event of an emergency. Regular audits were completed in relation to health and safety and infection control. Action was taken to address any shortfalls. The registered manager and operations manager completed other audits related to the quality of care and people’s care plans. The registered manager attended local forums and met regularly with the registered managers of the provider’s other services. These meetings were used for support and to share learning. The registered manager sought opportunities to continue their own personal development.

The registered manager gathered feedback from people, relatives, staff and visiting professionals. This was analysed and a report was available for people and visitors in the hallway. If issues were raised the registered manager arranged to meet with the person who had raised the concerns to address them directly and find a resolution. There was a complaints procedure in place; an easy read version of this was displayed around the service. People were also given the opportunity to raise any concerns in regular resident’s meetings. When complaints were received they had been investigated and responded to appropriately.