CQC report explained · a residential care home
What the CQC found at The Tudors Care Home
Rated Outstanding: inspectors found the home performing exceptionally well.
- Safe?
- Good
- People were protected by trained staff, suitable staffing levels and risk assessments. Inspectors found some risks because medicines cabinet keys were kept in an unlocked cupboard and hand hygiene was missed after medicines were handled.
- Effective?
- Good
- People's needs were assessed and reviewed, and staff had relevant training. People were supported with food, drink, healthcare, communication and decisions about their care.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect and supported their independence. This rating had fallen from Outstanding at the previous inspection.
- Responsive?
- Outstanding
- Care was highly personalised. People were supported to write their own care plans, communicate in ways that suited them, follow their interests and maintain relationships.
- Well-led?
- Outstanding
- Leadership and governance were exceptionally strong. People, relatives and staff were listened to, and audits and partnership working were used to improve care.
What inspectors found, August 2021
The Tudors Care Home was rated Outstanding; inspectors found highly personalised care and strong leadership, with some medicines and infection-control practices needing attention.
This was an unannounced inspection on 02 July 2021. Inspectors spoke with people living in the home, a relative and staff. They observed care and reviewed care plans, medicines records, staff records and management information.
The home was rated Good for Safe, Effective and Caring. It was rated Outstanding for Responsive and Well-led. Inspectors found people were treated with kindness, supported to make choices and helped to live meaningful, individual lives.
The inspection was partly prompted by concerns about safety, staffing, infection control, complaints and management. Inspectors found no evidence that people were at risk of harm from these concerns. They did identify risks around the security of medicines cabinet keys, medicine information and hand hygiene after medicines were handled.
Personalised care plans
People were supported to write their own care plans, so their preferences and wishes were recorded in detail and followed by staff.
“Staff went above and beyond what was expected to ensure people could write their own care plan, so care was truly individual.” from the report
Communication support
The home provided different ways for people to communicate and access information, including braille, audio books, pictures and voice-activated devices.
“People's independence and access to systems and technology greatly enhanced people's communication skills, including in their own language, using pictures, audio books or braille.” from the report
Meaningful lives
People were helped to continue hobbies, take part in cultural and religious celebrations, go out and contribute to the local community.
“The service supported and enabled people to take part in a wide range of hobbies, interests and pastimes, and to play an active part of the local community.” from the report
Strong leadership
Inspectors found an open culture where people and staff were listened to. Management systems identified improvements and tracked whether actions were completed.
“Audits and governance systems were very effective in identifying and implementing improvements.” from the report
Medicines cabinet key security
needs fixingThe medicines cabinet keys were found in an unlocked cupboard inside a staff member's jacket pocket. Inspectors said this created a risk that someone could access them.
“However, we found the keys were held in an unlocked clean-linen cupboard in a staff member's jacket pocket.” from the report
Hand hygiene after medicines
needs fixingAfter removing gloves, a staff member did not use the foot pedal on the bin and did not wash or sanitise their hands after moving the medicines trolley. Inspectors said this created a risk of cross-contamination.
“There was also no handwashing or hand sanitiser used even though the staff member moved the medicines trolley.” from the report
Medicine information
needs fixingOne person's blister-pack medicines did not have descriptions, so staff would not know which medicine had been refused. The manager said this would be added.
“Where people had their medicines in a blister pack there was no description what each one was.” from the report
- 01How are medicines cabinet keys now stored and checked so that they cannot be accessed by unauthorised people?
- 02What changes have been made to handwashing, hand sanitiser and bin-use procedures after medicines are administered?
- 03Has the missing description for each medicine in blister packs been added, and how are staff told which medicine was refused?
- 04How will you maintain the Outstanding standard for personalised care while improving the areas rated Good?
- 05How are people and relatives able to raise concerns, and what changes have been made in response to recent complaints?
This was an unannounced inspection covering all five key questions, including infection prevention and control; a focused inspection in February 2021 looked only at infection prevention and control and did not provide a rating. This explanation was written from the published report of 3 August 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2021
The Tudors Care Home was inspected but not rated; inspectors found several infection-control safeguards, alongside problems with PPE, waste storage and cleaning arrangements.
This was an unannounced, targeted inspection on 2 February 2021. It looked at infection prevention and control during a coronavirus outbreak. The home had 27 older people living there at the time.
Inspectors found good practice in visitor controls, testing, safe admissions and support for people to keep in touch with relatives by phone or video. Staff also used individual guidance to support people's wellbeing while face-to-face visits were stopped.
However, inspectors were only somewhat assured in several areas. Some staff did not wear PPE correctly, staff belongings were stored unsafely, clinical waste bins were not locked and were overflowing, and a communal lounge was cluttered.
The service was inspected but not rated. This means the report does not give an overall quality rating or a rated score for Safe. It was a focused check of infection-control arrangements rather than a full inspection of the home.
Testing and admissions
The home had arrangements for testing people and staff and for admitting people safely.
“We were assured that the provider was admitting people safely to the service.” from the report
Visitor infection controls
The home followed guidance for external health and social care professionals and had controls to reduce infection risks from visitors.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Keeping people connected
With face-to-face visits stopped during the outbreak, people were supported to use video and telephone calls and received personalised wellbeing guidance.
“People were being supported with video call and telephone calls in place of face to face visiting.” from the report
Cleaning empty rooms
An external company was used alongside the home's cleaning staff to sanitise rooms after they became empty.
“An external company was also used in addition to in-house cleaning staff, to come in and sanitize a room after it became empty.” from the report
PPE was not always worn correctly
seriousInspectors saw some staff wearing PPE incorrectly. The concern was corrected when raised, but inspectors said this increased infection risk.
“Most staff wore their PPE correctly, but we had to notify the Quality Assurance Manager on occasion when staff were seen not wearing their PPE correctly.” from the report
Unsafe storage of belongings
needs fixingThere were not enough lockers, so staff belongings were put in bin bags, with some left on the communal dining-room floor. The report says this was corrected.
“There were not enough locker spaces for staff to put their belongings away safely.” from the report
Clinical waste problems
seriousExternal clinical waste bins were not locked and were overflowing, with some spillage. Extra collection and another bin were requested.
“We also saw external clinical waste bins were not locked, overflowing with some spillage.” from the report
Clutter affecting cleaning
needs fixingThe communal lounge had many ornaments, which could make effective cleaning harder. The report says this was corrected.
“The residential communal lounge was quite cluttered with ornaments which could increase the risk of ineffective cleaning taking place.” from the report
Audit did not identify issues
needs fixingThe infection-control audit shared with inspectors had not picked up the improvements that inspectors found were needed.
“The infection control audit shared with the inspection team had not identified the areas of improvement required during our visit.” from the report
- 01Have all staff had a reminder or refresher about wearing PPE correctly, and how do you check this now?
- 02Have the extra clinical waste bin and additional collections been put in place, and are all clinical waste bins now locked?
- 03How are staff belongings stored safely so they are not left on communal floors?
- 04What changes were made to the communal lounge to make cleaning effective?
- 05How do you make sure your infection-control audits identify problems found during inspections?
This was an unannounced, targeted inspection of infection prevention and control during a coronavirus outbreak; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 3 March 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of The Tudors Care Home
2 rated inspections over 3 years: the service has held its Outstanding rating throughout.
- August 2021Outstandingcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Outstanding
- March 2021Inspected but not ratedSafe: Inspected but not rated
- June 2018OutstandingSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- May 2017
Registered with the Care Quality Commission on 19 May 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
39 live-in carers within about an hour of Peterborough
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,370 a week. 34 can care for a couple. 11 years' experience on average.
“I honestly feel lucky to have found her and have already booked her for another visit.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.