CQC report explained · a residential care home
What the CQC found at Tudor Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments and guidance were not always detailed enough, and medicines were not always managed safely. Staffing levels had improved, but the home did not use a consistent tool to show how staffing needs were calculated.
- Effective?
- Requires improvement
- This key question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Requires improvement
- Audits did not identify all the shortfalls found by inspectors, and there was no clear, comprehensive action plan to address them. Relatives and staff said managers were approachable and open to concerns.
What inspectors found, November 2022
Rated Requires Improvement; inspectors found risks and medicines were not always managed safely, and quality checks had missed important problems.
This was an unannounced focused inspection. The inspection visit took place on 03 October 2022, with inspection activity continuing until 11 October 2022. Inspectors looked at Safe and Well-led, including infection control. They spoke with people, relatives and staff, observed care and reviewed care plans, medicines, recruitment records and management checks.
The home was not always safe. Risk assessments did not consistently explain how staff should reduce risks. Some people had not received medicines as prescribed, and medicines records were incomplete. Staffing had improved by the inspection, but there was no consistent method to calculate staffing needs when people's needs changed.
The home was not always well-led. Quality audits had not identified the full extent of the problems, and there was no comprehensive action plan to put things right. The CQC found breaches of Regulation 12 on safe care and treatment and Regulation 17 on good governance.
The overall rating changed from Good at the previous inspection to Requires Improvement. This rating is based on the findings from this focused inspection, together with ratings carried forward for the areas that were not inspected.
People appeared comfortable
People appeared happy and relaxed with staff. People and relatives said they felt safe and well looked after.
“People appeared to be happy and relaxed in the company of staff.” from the report
Safe recruitment
The home completed recruitment checks before staff started work, including checks about their character.
“Staff were recruited safely. Checks had been completed before staff started work at the service” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections and was using protective equipment safely.
“We were assured that the provider was using PPE effectively and safely.” from the report
Support with decisions
Staff supported people to make choices wherever possible and used objects or pictures to help people understand their options.
“People were offered choices in the way they could understand such as being shown objects or pictures.” from the report
Open communication
Relatives said they could speak to the manager about concerns and were told when their relative fell or became unwell.
“Relatives told us they were told when things went wrong.” from the report
Risk assessments
seriousRisks to people's health and welfare were not consistently assessed. Staff did not always have enough guidance to reduce risks, including risks linked to distress, diabetes, weight loss and catheters.
“Potential risks to people's health and welfare had not been consistently assessed” from the report
Medicines
seriousSome medicines records did not show who had given a medicine or when. One person's records showed staff had signed to say a medicine had been given when it had not.
“People had not always received their medicines as prescribed.” from the report
Quality monitoring
seriousThe home's audits did not identify all the problems found by inspectors. There was no clear action plan showing how shortfalls would be corrected and checked.
“there was no clear action plan in place to rectify these.” from the report
Staffing calculations
needs fixingStaffing levels had been low at times because of staff leaving and sickness. Although levels were stable during the inspection, the home did not use a tool to show how many staff were needed.
“Staffing levels had not always been consistent. The nominated individual explained staff had left and there had been sickness” from the report
Learning from incidents
needs fixingAccidents and incidents were recorded and analysed, but the home did not consistently check whether actions taken had worked.
“However, there was no review to check if the action had been effective.” from the report
- 01What changes have you made to risk assessments and care plans since the inspection, especially for diabetes, weight loss, distress and catheter care?
- 02How do you now check that medicines are given as prescribed and that controlled medicines records are complete?
- 03What action plan was sent to the CQC, and which improvements have been completed?
- 04How do you calculate the number of staff needed when people's needs change or there is sickness?
- 05How are external audits being used to check that the problems found in this report have been fixed?
This was a focused inspection of Safe and Well-led, including infection control; the other key-question ratings were carried forward from the previous inspection. This explanation was written from the published report of 18 November 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, January 2021
Rated Good; inspectors found safe, kind care and better management, with minor record-keeping and cleaning issues still noted.
This was a focused inspection on 1 December 2020. Inspectors checked whether earlier concerns about safety and management had been fixed. They spoke with staff, relatives and a social care professional, observed people, and reviewed care, medicine, staffing and management records.
The home was calm and people appeared well cared for. Staff were kind. Inspectors found enough staff, safe recruitment, suitable risk assessments and good infection control arrangements during the COVID-19 pandemic. Medicines were managed more safely, including daily checks and clearer guidance for medicines given only when needed.
The home was rated Good overall, and Safe and Well-led were both rated Good. The previous rating was Requires improvement, with breaches of regulations about medicines and governance. Inspectors found enough improvement had been made and there were no current breaches. This was a focused inspection, so the other three question ratings were carried forward from the previous comprehensive inspection.
Kind and calm care
People appeared settled and well cared for. Staff were seen treating people with kindness and respect.
“Staff were observed to be kind and caring when supporting and assisting people.” from the report
Safer medicines
Daily medicine checks had been introduced, and sampled medicine balances matched the records. Guidance was also available for medicines given only when needed.
“The recorded balances tallied with the actual amount of remaining boxed medicines.” from the report
Enough trained staff
Staffing levels were based on people's needs. Recruitment checks had been completed and staff received relevant training.
“There were enough staff to support people receiving the service, and there was a safe system for their recruitment.” from the report
Improved management
The management team had introduced more regular audits and action plans. Staff said they felt better supported and worked well together.
“This system gave assurance that standards in all areas were being monitored and maintained.” from the report
Care records needed updating
minorSome changes in people's needs were not accurately recorded in care records. Inspectors said staff knowledge reduced the impact, but the records still needed to be kept correct.
“We signposted them around the need to ensure changes for some people were accurately documented in care records.” from the report
Cleaning standards
minorInspectors noted minor improvements were needed in cleaning. The provider said this had already been identified and was being addressed.
“We did note minor improvements to the standard of cleaning and discussed this with the provider who was able to provide assurance this had already been identified and was being acted upon.” from the report
- 01How do you make sure changes in a person's needs are recorded promptly and accurately?
- 02What cleaning improvements were identified, and have they now been completed?
- 03Have both medicine rooms finished refurbishment, including the air conditioning work?
- 04How will you keep families informed about visiting arrangements and changes during the COVID-19 pandemic?
- 05What are the current ratings for Effective, Caring and Responsive from the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 1 January 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 Tudor Lodge
5 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- May 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016
Registered with the Care Quality Commission on 31 October 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.
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 Kent
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 £1,260 a week. 33 can care for a couple. 12 years' experience on average.
“Always on time and with a lovely smile for my mum. Theresa is kind and sensitive to my mum's needs.”
“Irene was a very kind and empathetic carer who knew just the right words to say to put a smile on my face.”
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.