1 August 2023
During an inspection looking at part of the service
Tudor Manor is a residential care home providing personal care for maximum of 22 people. The service provides support to people aged 65 and provides dementia care to individuals. At the time of our inspection there were 20 people using the service.
People’s experience of using this service and what we found
Risks to people were not continually assessed and mitigated. Fire safety practices were not robust. There was a lack of oversight and monitoring of daily care. Safeguarding concerns were not consistently escalated to external professionals. Systems and processes to safeguard people from the risk of abuse were not embedded in the home. .
Staff were not recruited safely, safety checks carried out on individuals employed by the home were not carried out to ensure vulnerable people living in the home were safe.
There were infection control measures in place, however we were not assured the provider had considered shielding and social distancing rules, when people shared bedrooms. Accidents and incidents were recorded but not analysed for themes and trends. People received their medications as prescribed. Relatives were encouraged to visit their loved ones.
The provider lacked understanding around the Mental Capacity Act, we found that people were not correctly assessed for their mental capacity, meaning decisions people could make were unclear. Care records lacked personal characteristic and information about how to support people with specific health needs. We found people who were receiving respite care did not have a care plan in place.
Staff training records showed gaps in mandatory essential training, meaning staff were not fully trained.
Staff worked with external professionals to promote a partnership approach to care. However, staff did not always escalate concerns in a timely manner. The service had not been adapted to meet people’s needs and lacked person centred detail.
People were supported to eat and drink and told us they enjoyed the food. People had choices in the food they ate and could change their mind and have alternative meals.
Improvements were needed to ensure people’s end of life documents were up to date and reflected their wishes. The provider did not always explore the most effective way to communicate with people.
For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement 11 February 2022.
At our last inspection we found breaches of the regulations in relation to good governance. The provider completed an action plan after the last inspection to tell us what they would do and by when to improve.
At this inspection, we found the provider remained in breach of regulations.
Why we inspected
We received concerns in relation to the management of the service and people’s safety. As a result, we undertook a focused inspection to review the key questions of safe, effective, responsive, and well-led..
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 requires improvement to inadequate. This is based on the findings at this inspection.
We have found evidence that the provider needs to make improvements.
Please see the safe, effective, responsive and well-led sections of this full report.
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 Manor on our website at www.cqc.org.uk
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.
Enforcement
We have found breaches in relation to safe care and treatment, safeguarding people from abuse and improper treatment, need for consent, fit and proper persons employed and good governance.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
The overall rating for this service is inadequate and the service is therefore in special measures. This means we will keep the service under review and will re-inspect within six months of the date we published this report to check for significant improvements.
If the registered provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question, we will take action in line with our enforcement procedures. This usually means that if we have not already done so, we will start processes that will prevent the provider from continuing to operate the service.
For adult social care services, the maximum time for being in special measures will usually be 12 months. If the service has shown improvements when we inspect it, and it is no longer rated inadequate for any of the five key questions, it will no longer be in special measures.