CQC report explained · a residential care home
What the CQC found at Tudor House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found people were protected from abuse and there were enough staff on the inspection day. However, infection control records, some medicine processes and some safety checks needed improvement.
- Effective?
- Good
- This question was not inspected during this focused inspection. The report says ratings for questions not inspected were carried over from the last inspection.
- Caring?
- Good
- This question was not inspected during this focused inspection. People spoken with were happy with the care, and relatives were mostly satisfied with the support provided.
- Responsive?
- Good
- This question was not inspected during this focused inspection. The report says ratings for questions not inspected were carried over from the last inspection.
- Well-led?
- Requires improvement
- There was no permanent registered manager, communication was poor and staff said they lacked direction, supervision and team meetings. Quality monitoring did not identify or resolve several problems.
What inspectors found, March 2022
Rated Requires Improvement; inspectors found caring staff and some safety measures, but weak management, poor communication and medicine recording problems.
This was an unannounced focused inspection on 25 January and 3 February 2022. Inspectors first checked infection control and COVID-19 arrangements, then widened the inspection to Safe and Well-led after finding concerns.
People spoken with were happy with their care, and relatives were mostly satisfied. Inspectors found enough staff on the inspection day, suitable recruitment checks, safeguarding knowledge, regular risk reviews and generally safe support with medicines. There were minor problems with medicine records and storage.
The main concerns were management and oversight. There had been no permanent registered manager since November 2020. Communication with families and staff was poor, staff lacked regular supervision and meetings, and quality checks had not identified several problems. The provider breached Regulation 17 on good governance.
The overall rating fell from Good at the previous inspection to Requires Improvement. The provider had taken immediate action on some concerns, and CQC said it would request an action plan and monitor progress.
Safeguarding
Staff knew how to report abuse and had completed safeguarding training. Inspectors found that risks to people were reviewed regularly.
“Staff had completed their safeguarding training and knew how and who to report concerns to.” from the report
Staffing and recruitment
Inspectors saw enough staff to support people safely on the inspection day. Recruitment checks were in place to assess whether staff were safe to work with people.
“Our observations on the day of inspection showed there were enough staff on duty to support people safely.” from the report
Care and professional links
People said they were happy with the care, and the home worked with health and social care professionals to help meet people's needs.
“There was evidence to support the service worked well with health and social care professionals to make sure people's needs continued to be met.” from the report
Action during inspection
The provider introduced several infection control processes between the two inspection visits, including improved testing records, visitor checks and PPE disposal.
“At the 03 February 2022 inspection, processes and records had been introduced to address this concern.” from the report
Weak management oversight
seriousThe home had no permanent registered manager and the provider did not have clear systems for checking and improving quality. This was a breach of Regulation 17.
“There was a lack of provider oversight in the absence of a registered manager. There were no clear governance processes in place.” from the report
Poor communication
needs fixingRelatives and staff reported poor communication and uncertainty about who was responsible for the home. There was no clear single point of contact for families.
“Family members felt there was no single point of contact to raise concerns and overall communication from the service was poor.” from the report
Medicine records
needs fixingSome medicines were not recorded or stored correctly. Audits had not identified inaccurate liquid medicine balances or medicines recorded as returned when they had not been returned.
“Medication audits had not identified liquid medicines were not being monitored effectively.” from the report
Infection control training
needs fixingNot all staff were up to date with, or had received, infection prevention and control training. Some infection control processes were improved during the inspection.
“Training records seen showed not all staff were up to date with or had received infection prevention and control training.” from the report
Weight monitoring
needs fixingWeight records were inconsistent, and the report did not confirm that the weighing machine had been calibrated or that a consistent weighing method was used.
“There was no information to confirm when the weighing machine had last been calibrated or if a consistent way to weigh people was being followed.” from the report
- 01Who is currently responsible for managing the home, and when will the registered manager application be completed?
- 02What changes have been made to medicine records, liquid medicine balances and the checking of returned medicines?
- 03How are you making sure all staff complete infection prevention and control training?
- 04How are relatives told about changes, weight loss or other concerns affecting their family member?
- 05What consistent method is now used for weighing people, and how do you check that the weighing machine is accurate?
This was a focused inspection of Safe and Well-led, mainly covering infection control, medicines, safety systems and management; the other key-question ratings were carried over from the previous inspection. This explanation was written from the published report of 24 March 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, December 2019
Tudor House was rated Good overall; inspectors found safe, kind and personalised care, with previous concerns about leadership improved.
Inspectors made an unannounced visit on 20 November 2019. They spoke with people living in the home, relatives, staff and a visiting healthcare professional. They also observed care and checked care plans, medicines records, recruitment information, incidents and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines support, suitable risk assessments, good infection control and access to healthcare. People were treated with kindness, involved in decisions and supported according to their individual needs and preferences.
The previous overall rating was Good, published in May 2017. Well-led had previously been Requires Improvement, but this improved to Good at this inspection. Inspectors found that the management team had systems to monitor quality and make improvements.
Safe care and medicines
Inspectors found that staff understood people's risks and supported them safely. Medicines were given by trained and competent staff, with guidance for medicines given when needed.
“People were safely supported with their medicines by a trained and competent staff team.” from the report
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors saw calm, friendly interactions and support that respected people's choices, privacy and dignity.
“Throughout this inspection we saw staff members chatting with people and relatives in a relaxed and engaging manner.” from the report
Personalised care
Staff knew people's histories, preferences and support needs. Care plans were reviewed when people's health or circumstances changed.
“Staff members could tell us about those they supported in detail indicating they knew people well.” from the report
Good support for health and nutrition
People could choose meals and were offered alternatives. Staff arranged specialist assessments and followed healthcare advice when needed.
“People had access to additional healthcare professionals including GP's, dentists and chiropodists.” from the report
Improved leadership
The well-led rating improved from Requires Improvement to Good. Inspectors found quality monitoring systems and an approachable management team.
“At this inspection this key question had now improved to 'Good.'” from the report
Previous recording problem
minorQuality checks had found that staff had not consistently recorded the use of people's topical creams. The home introduced a different checking system, and inspectors found the records were then completed as required.
“they highlighted staff members had not consistently recorded people's topical creams.” from the report
- 01How do you now check that topical creams and other treatments are recorded correctly?
- 02How do you assess and review each person's risks, including risks linked to mobility, skin and nutrition?
- 03How do you make sure staff know each person's preferences, health needs and care plan?
- 04How are people and relatives involved when care plans are reviewed or health needs change?
- 05How do you check that staffing levels remain sufficient for the people living in the home?
This was an unannounced inspection covering all five key questions; the previous overall rating was Good, while the previous Well-led rating of Requires Improvement had improved to Good. This explanation was written from the published report of 10 December 2019 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 House
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- March 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2019Goodstayed GoodSafe: GoodWell-led: Good
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 January 2011.
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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