CQC report explained · a residential care home
What the CQC found at Tudor Avenue Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and reviewed, staffing levels were adequate, medicines were managed safely and infection control arrangements were good.
- Effective?
- Good
- People received individualised care, staff had relevant training and support, and people were supported with food, drink, healthcare and decisions about their care.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Leadership was open and supportive, but electronic care planning and training systems were not working well enough, and information from a serious incident review was delayed.
What inspectors found, February 2022
Tudor Avenue Residential Care Home was rated Good overall; inspectors found safe, effective care but leadership and record systems required improvement.
This was a focused inspection on 11 November 2021. Inspectors reviewed Safe, Effective and Well-led after receiving concerns about moving and positioning. They spoke with one person, three care staff and the registered manager, and reviewed two people's care records and other records.
The home was rated Good for Safe and Effective. Inspectors found enough staff, safe medicines systems, suitable safeguarding arrangements and good infection control. People received individualised care, staff had training and support, and people were helped to make choices and access healthcare.
The Well-led rating was Requires Improvement. Electronic care planning and training systems were difficult to use, and a serious incident review had not reached the registered manager until the day before the inspection. The overall rating stayed Good, with ratings for Caring and Responsive carried over because they were not inspected.
Safe staffing and medicines
Inspectors found enough staff to support people safely. Medicines records were accurate and staff had their competence checked.
“There were adequate numbers of staff to help keep people safe.” from the report
Personalised support
People were supported to make choices, maintain independence and take part in activities. Their privacy and dignity were respected.
“People were supported to engage in a range of activities and their independence was promoted.” from the report
Health and food support
People helped plan meals and could change their choices. The home worked with healthcare professionals and used hospital passports to support transfers.
“The provider worked in partnership with other agencies to ensure people's health needs were met.” from the report
Clean and infection-safe home
The home was clean and tidy, with suitable supplies and practices to reduce infection risks.
“We were assured that the provider was using Personal Protective Equipment (PPE) effectively and safely.” from the report
Care planning system
needs fixingStaff and managers reported that the electronic care planning system was complicated and slow. The organisation said further work was taking place to improve it.
“Staff reported problems in using the electronic care planning system” from the report
Training records
needs fixingMultiple electronic training systems made it difficult to keep accurate records and confirm that training was up to date.
“This caused difficulties in ensuring accurate information was maintained to provide assurance that staff training was up to date” from the report
Delayed incident information
needs fixingThe registered manager received the serious incident review only the day before the inspection, even though it contained actions intended to reduce the risk of repeat incidents.
“This was of concern given the report contained actions regarding moving and positioning practice for the registered manager” from the report
- 01What changes have been made to the electronic care planning system since the inspection?
- 02How do you now check that every staff member's training record is accurate and up to date?
- 03What action was taken after the serious incident review, and how was the learning shared with staff?
- 04What are the current arrangements for moving and positioning support if a resident's mobility needs change?
- 05What are the current ratings for Caring and Responsive, which were not inspected during this visit?
This was a focused inspection of Safe, Effective and Well-led following concerns about moving and positioning; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 16 February 2022 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, November 2017
Tudor Avenue Residential Care Home was rated Good; inspectors found safe, caring and personalised support across all five areas.
Inspectors visited without notice on 2 October 2017. They spoke with four people, four relatives, the registered manager and staff. They also observed care, checked the home and reviewed care, staff and management records.
People were described as happy and safe. Inspectors found kind and respectful care, suitable staff training, safe medicines management, up-to-date care plans and support from health professionals. People were helped to make choices, stay in contact with family and take part in activities in the home and community.
The home was rated Good for Safe, Effective, Caring, Responsive and Well-led. It had also been rated Good at the previous inspection in September 2015. This was the first inspection since the registered provider changed in 2016.
Safe care
Inspectors found that staff understood safeguarding and that individual and environmental risks were assessed and reviewed. Medicines were stored, administered and recorded safely.
“Medicines, including controlled medicines were safely and securely stored in a locked medication cupboard and staff had received up to date training.” from the report
Kind and respectful staff
Staff knew people well and supported them at their own pace. People were treated with respect, compassion and dignity.
“Positive caring relationships were developed with people and they were treated with respect and compassion in their day-to-day care.” from the report
Personalised activities
Activities were based on people's interests and included trips into the community, swimming, music therapy, cinema visits and holidays.
“There was a full programme of personalised activities for people which included community based activities.” from the report
Good records and reviews
Care plans and communication guidance were kept up to date. This helped staff respond to changing needs and follow advice from health professionals.
“The care plans contained clearly recorded and up to date information which was regularly reviewed.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you keep my relative's individual risk assessments up to date as their needs or interests change?
- 02What training and experience do staff have for supporting complex dietary needs, including PEG or RIG care if needed?
- 03How will you help my relative take part in activities that match their interests and preferred routines?
- 04How will you involve our family in best-interest decisions and reviews of care?
- 05How do your quality audits and staff meetings lead to improvements in my relative's care?
This was an unannounced inspection covering all five CQC questions, and it was the first inspection under the new registered provider. This explanation was written from the published report of 8 November 2017 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 Tudor Avenue Residential Care Home
2 rated inspections over 4 years: the service has held its Good rating throughout.
- February 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Tudor Avenue Residential Care Home →
- November 2017GoodSafe: GoodEffective: GoodWell-led: Good
Read what inspectors found at Tudor Avenue Residential Care Home →
- February 2016
Registered with the Care Quality Commission on 18 February 2016.
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.
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Most charge £980 to £1,270 a week. 78 can care for a couple. 11 years' experience on average.
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