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Tudor Court Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 18 January 2019

The inspection took place on 2 and 7 November 2018 and the first day was unannounced. At the last inspection of the service in October 2016 the provider was rated as Good in all five key questions. At this inspection, we found that the key questions of Safe and Well Led were now rated as Requires Improvement.

Tudor Court is a 'care home'. People in care homes receive accommodation and nursing or 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 Court is registered to provide care, nursing and accommodation to a maximum of 29 older people, some of whom may be living with dementia or memory loss. At the time of the inspection, there were 21 people living at the home.

There was 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.

Prior to the inspection we received a number of concerns about insufficient staffing levels, pressure area care and adequate welfare checks and supervision of people living in the home. As a result of these concerns we brought our comprehensive inspection forward to look into the care provided at Tudor Court.

Risks to people were assessed and risk assessments tools were used to identify common risks such as those relating to falls, skin integrity and medicines. However, daily monitoring records did not always show that care was being delivered as it should and checks on equipment used to reduce risk, were not always accurate. People were not always protected from risks associated with their environment. Some windows did not have window restrictors and one radiator did not have a cover fitted.

Improvements were required to ensure that medicines were managed safely. Whilst medicines were stored and administering safely, random sampling of five medicines found discrepancies with the stock levels of two medicines and staff were unable to tell us how much stock they should have of another medicine. During the inspection the registered manager amended their daily medicines audit to include stock checks of boxed medicines.

The provider had systems in place to monitor the quality and safety of the home, however, these were not always robust nor effective because they had failed to identify and address the issues we found during this inspection.

People and relatives had differing opinions about the amount of staff available and if there was enough staff to meet people’s needs. One person told us, “It seems to be fine. There are always some staff around. I have no concerns.” However, another person told us, “They can be rushed off their feet." Staff also felt they were short staffed. One said, “It’s terrible we are constantly short staffed. We are not spending enough time with people. The only time you spend with residents is when you get them up in the morning.” We made a recommendation to the provider to review their staffing levels to ensure people’s needs were met.

We found that improvement was needed in relation to supporting people to maintain their social activities and interests to avoid the risk of social isolation. The provider arranged a programme of entertainers that came into the home to provide activity. There was no activity coordinator. The responsibility to generate activity fell to the staff team. However, staff told us, and we observed, that staff rarely had time to sit with people and engage them in an activity they enjoyed. One person told us, “There’s nothing you can do here, only sit in the chair.” People and staff told us that staff talked to them when providing care but did not have time to spend with them for one to one activities. We made a recomm

Inspection areas


Requires improvement

Updated 18 January 2019

The service was not always safe.

People could not be assured risks to their health, safety and well-being would be managed safely.

Systems and processes in place to ensure the safe handling of medicines had not always been properly followed.

We made a recommendation about ensuring there was enough staff available to meet people’s needs.

Staff had been trained in safeguarding people and were knowledgeable about the potential signs of abuse.



Updated 18 January 2019

The service was effective.

Staff received training and support to enable them to carry out their roles effectively.

People's capacity to make decisions about their care had been assessed in line with the Mental Capacity Act 2005.

People told us the food was good and choices were available to them.

People's health and nutritional needs were regularly assessed and referrals made to appropriate health professionals when necessary.

The premises were designed, adapted and decorated to meet people's needs and wishes.



Updated 18 January 2019

The service was caring.

People told us staff were always kind and caring.

People were treated with dignity and respect.

We observed good relationships between staff and people living in the home.

People were encouraged to retain an appropriate level of independence.

Staff supported people to maintain contact with their family.


Requires improvement

Updated 18 January 2019

The service was not always responsive.

The provider arranged a programme of entertainers to come into the home to provide activity for people. We made a recommendation about the provision of one to one activity.

People's care plans were comprehensive, person centred and detailed, providing staff with relevant and appropriate guidance in how to support each person.

There was a complaints system and people knew how to complain.

People were supported to have a dignified end to their life.


Requires improvement

Updated 18 January 2019

The service was not always well-led.

The systems in place to monitor the quality and safety of the service had not been used effectively; this had led to the shortfalls identified during this inspection.

People, their relatives and staff were positive about the leadership at the service. Staff felt supported by the management.

People and their relatives were provided with opportunities to provide their feedback on the quality of the service.

The registered manager understood their regulatory responsibility and had submitted statutory notifications as required.