CQC report explained · a nursing home
What the CQC found at Tudor House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Some window restrictors needed adjusting to reduce the risk of falls from height. The home had not completed a water hygiene risk assessment, although medicines, staffing, infection control and individual risk plans were found to be suitable.
- Effective?
- Good
- Staff had suitable training and support. People received healthcare, food choices and support with their health, oral care and legal rights.
- Caring?
- Good
- People liked the staff, who knew them well and treated them with dignity and respect. People were involved in decisions about their care.
- Responsive?
- Good
- Care plans were personalised and kept up to date. People had activities, support to keep in touch with relatives and suitable end-of-life care.
- Well-led?
- Good
- The home had experienced management, regular meetings and checks on care quality. However, its audits had not identified the problems with window restrictors and water safety.
What inspectors found, April 2020
Tudor House Nursing Home rated Good; inspectors found kind, personalised care, but safety checks needed improvement.
This was an unannounced planned inspection on 13 February 2020. The inspection team spoke with people living at the home, relatives, staff and a health professional. They reviewed care records, medicines records, staff files, audits and other management records.
The home was rated Good overall. Effective, caring, responsive and well-led were all rated Good. Inspectors found enough staff, safe medicines support, clean surroundings, good relationships and personalised care.
Safe was rated Requires Improvement. Some window restrictors were not adjusted correctly, which could increase the risk of falls from height. The home had also not completed a water hygiene risk assessment. The provider said these issues would be dealt with immediately.
The last inspection, published in August 2017, rated the home Good overall and Good for every key question. Safe had fallen to Requires Improvement at this inspection.
Kind relationships
People liked the staff and inspectors saw staff treating people with patience, dignity and respect.
“People liked the staff who supported them and had good relationships with them.” from the report
Personalised care
Care plans included people's health needs, backgrounds, preferences and important relationships. Staff understood these plans and followed them.
“People's care plans detailed their health needs, their backgrounds, personalities, those who were important to them and how they preferred to receive their care.” from the report
Safe medicines support
Inspectors found that medicines were given as prescribed and handled securely by trained nurses.
“Our checks of medicines stocks and records showed people received their medicines as prescribed.” from the report
Enough staff
Inspectors found enough staff were present and able to respond to people promptly.
“We observed there were sufficient staff with staff always present in communal areas.” from the report
Activities and food
People had activities based on their interests and were offered food choices they enjoyed.
“The activity officer followed an activity programme based on people's interests.” from the report
Window safety
seriousSome window restrictors were incorrectly adjusted. This meant people may have been at risk of falling from height.
“However, we identified some window restrictors were incorrectly adjusted so people may have been at risk from falls from height.” from the report
Water hygiene assessment
seriousThe home carried out water safety checks but had not assessed all the risks relating to water hygiene.
“However, the provider had not carried out a risk assessment to ensure any risks relating to water hygiene were identified and managed.” from the report
Recruitment records
minorThe home did not always record reasons for gaps in staff employment histories. The provider said this would improve.
“The provider did not always record reasons for any gaps in staff employment records and told us they would improve going forward.” from the report
Checks did not find all risks
needs fixingThe home's audits did not identify the problems with window restrictors and water safety management.
“However, these audits had not identified window restrictors were not always suitable to reduce the risk of falls from height and water safety management required improvement.” from the report
- 01Have all window restrictors now been checked and adjusted, and how do you record these checks?
- 02Has the water hygiene risk assessment now been completed, and what risks or actions did it identify?
- 03How do your audits now make sure that safety problems are found promptly?
- 04How do you record and check reasons for gaps in staff employment histories?
- 05What activities are currently available for someone with my relative's interests and needs?
This was an unannounced planned inspection covering all five key questions, with the CQC reviewing the premises and the care provided. This explanation was written from the published report of 2 April 2020 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, August 2017
Rated Good; inspectors found kind, safe care, but noted earlier staffing shortfalls and mixed views about food variety.
Inspectors visited on 30 June and 5 July 2017. The first visit was unannounced. They spoke with 15 people using the service, two relatives and six staff. They observed care, checked three care records, looked around the home and reviewed medicines, safety and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People generally said staff were kind, respectful and helpful. Medicines were stored and given safely, staff had suitable training, and people received support with health needs.
There were some issues to keep an eye on. Staffing had been short earlier in 2017 after experienced staff left, although new staff had been recruited and staffing levels had returned to normal. People gave mixed views about food variety and activities, and some records and management planning needed improvement.
The home was already rated Good at the inspection in May 2016. This inspection found it remained Good overall. The Effective rating improved to Good, while the other four ratings remained Good.
Kind and respectful care
People described staff as polite and helpful. Inspectors saw staff respecting privacy, dignity and personal choices.
“Our observations showed staff were kind, caring and treated people with respect.” from the report
Safe medicines
Medicines were stored securely, given correctly and checked against stock records.
“We saw medicines were stored safely and securely and our checks showed that medicines were being administered correctly.” from the report
Trained staff
Staff received regular training, supervision and appraisals relevant to their roles and the needs of people living at the home.
“We saw staff completed training relevant to their role and responsibilities.” from the report
Health support
People were supported to access health professionals when needed. Care records showed this support was arranged and followed up.
“People were supported to keep healthy and had access to appropriate health care professionals when needed.” from the report
Activities and family links
The home offered regular activities, community trips and opportunities for relatives and friends to be involved.
“Activities were used to help keep people connected to the local community and their family and friends.” from the report
Earlier staffing shortfalls
needs fixingThere had been staffing gaps earlier in 2017 after experienced staff left and sickness affected some shifts. People gave mixed views about whether there were enough staff.
“Feedback about staffing levels was however mixed and the registered manager acknowledged there had been staffing shortfalls earlier in 2017” from the report
Limited menu choice
minorSome people wanted more variety in the food and menus. The registered manager agreed to review the menus.
“Some people using the service said they enjoyed the food provided to them whilst others said they would welcome more variety in the menus offered.” from the report
Care plans not always personal
needs fixingCare plans were reviewed regularly, but many focused mainly on physical and health care rather than emotional wellbeing.
“The plans differed as to how individualised they were with many focusing mainly on the health and physical care provided.” from the report
Some capacity records incomplete
needs fixingSome mental-capacity assessments, including those relating to covert medicines, were not completed consistently.
“Some assessments seen however were inconsistently completed and we highlighted this to the registered manager during our inspection.” from the report
More activity and interaction wanted
minorSome people wanted more activities, and one relative felt there was too much reliance on television and not enough interaction from care staff.
“Three people using the service said they would welcome more activities.” from the report
Development plan missing
minorThe inspection found that an annual development plan was not available at the time.
“An annual development plans was not available at the time of inspection and we discussed this with the registered manager.” from the report
- 01What are staffing levels now, and how do you cover sickness or staff leaving?
- 02What changes were made to the menus after people asked for more variety?
- 03How do you make sure care plans reflect each person's emotional wellbeing as well as physical care?
- 04How are mental-capacity assessments checked for completeness, especially where medicines may be given covertly?
- 05What activities and one-to-one interaction are available for people who do not want to watch television?
This was a planned inspection covering all five CQC questions; the home remained Good overall, with Effective improving to Good and the other four ratings remaining Good. This explanation was written from the published report of 16 August 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 House Nursing Home
4 rated inspections over 5 years: the service has held its Good rating throughout.
- April 2020Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Goodstayed GoodEffective: Requires improvement
- April 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- October 2013
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.
- November 2010
Registered with the Care Quality Commission on 29 November 2010.
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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