CQC report explained · a residential care home
What the CQC found at Tudor Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe medicines processes, positive risk plans, suitable infection control and appropriate action when incidents occurred.
- Effective?
- Good
- Care plans reflected people's needs, strengths and aspirations. Staff had relevant training, people were supported with food and healthcare, and consent and best-interest processes were followed.
- Caring?
- Good
- People received kind and compassionate care. Staff respected privacy, dignity and personal choices, and supported people to communicate and develop independence.
- Responsive?
- Good
- Support was personalised and reflected people's communication needs, interests and relationships. People took part in activities, stayed in contact with family and could raise concerns or complaints.
- Well-led?
- Good
- The manager and staff created a person-centred and open culture. Governance systems were effective, families and professionals were consulted, and feedback was used to improve the service.
What inspectors found, November 2023
Tudor Lodge was rated Good in all areas; inspectors found safe, kind and personalised care with no breaches reported.
Inspectors visited on 4 and 5 October 2023. The first day was unannounced. One inspector spoke with people living at the home, relatives, staff and a healthcare professional, and checked care records, medicines, training and management records.
The home supported 7 people with learning disabilities or autism. Inspectors found enough staff, safe medicines systems, good infection control and a clean, suitable environment. People were supported to make choices, take positive risks, build independence and communicate in ways that worked for them.
People were treated with kindness and respect. Care was tailored to individual needs and interests, including activities, relationships, health support and community visits. The manager and staff team were described as open, supportive and focused on improving people's quality of life.
The overall rating was Good, with Good ratings for Safe, Effective, Caring, Responsive and Well-led. The rating was unchanged from the previous inspection, published in February 2018. The report does not record any breaches or enforcement action.
Consistent staffing
The home had enough staff, including for one-to-one support. Low staff turnover meant people were supported by a regular team who knew them well.
“The registered manager told us staff turnover was low which helped provide people with consistent care and support from a regular and familiar staff team.” from the report
Choice and independence
Staff encouraged people to make decisions, take positive risks and develop everyday skills. People were supported to do as much as they could for themselves.
“People had the opportunity to try new experiences, develop new skills, gain confidence and independence.” from the report
Kind and respectful care
Inspectors observed warm, patient and respectful interactions. Staff gave people time, space and choices without rushing them.
“People received kind, compassionate care from staff who used positive, respectful language which people understood and responded well to.” from the report
Personalised communication
Staff understood people's communication needs and used pictures, symbols, gestures and other methods to help people understand information and express their views.
“People had individual communication plans that detailed effective and preferred methods of communication, including the approach to use for different situations.” from the report
Activities and relationships
People were supported to maintain family relationships and take part in activities suited to their interests, including outings, exercise and community activities.
“We saw people were encouraged to take part in activities they enjoyed, for example, walks in the local area, dance classes, trampolining, bike riding, swimming, going out for meals and outings to places of interest in the community.” from the report
Inspectors raised no specific concerns in this report.
- 01How would you assess and record my relative's communication and sensory needs?
- 02How would you support my relative to build independence and take positive risks safely?
- 03Which staff would usually support my relative, and how do you manage one-to-one support for activities and visits?
- 04How would you support my relative to keep in contact with family and take part in activities they enjoy?
- 05How are medicines reviewed and checked, including medicines covered by STOMP principles?
This was an inspection of all five key questions and included infection prevention and control; the previous overall rating was Good, published on 28 February 2018. This explanation was written from the published report of 1 November 2023 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, February 2018
Tudor Lodge was rated Good; inspectors found kind, person-centred care, with some records and safety checks needing attention.
This was a comprehensive, unannounced inspection on 16 and 18 January 2018. It was the first inspection since the service registered with the CQC under its current provider. Inspectors spoke with people, relatives, managers and staff, observed care, and checked care plans, medicines, staff files and other records.
Inspectors found people were safe and supported by enough staff with suitable skills. Medicines were managed safely, the home was clean, and risks were assessed. People were supported with food, drinks, healthcare and daily choices.
Staff were kind and respectful. They knew people well and used different ways to communicate with those who could not speak. Care plans were detailed and regularly reviewed. People were supported to take part in activities, keep relationships and make choices.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The report also identified some improvements needed, including renewing some training, completing delayed staff supervision, and carrying out a fire risk assessment.
Kind and respectful staff
Inspectors saw relaxed relationships between people and staff. Staff used positive communication and treated people with dignity and kindness.
“Staff used enabling and positive language when talking with or supporting people and treated people with respect and kindness.” from the report
Personalised support
Care records described people's histories, preferences, interests, communication needs and goals. Staff used this information in daily care.
“Care records were centred on people as individuals and contained detailed information about people's diverse needs, life histories, strengths, interests, preferences and aspirations.” from the report
Safe medicines arrangements
Medicines were stored securely and administered by trained staff. Inspectors found no recording errors in the medicine records they checked.
“We found no recording errors on any of the medicine administration record sheets we looked at.” from the report
Activities and independence
People were supported to choose activities, go out, follow hobbies and remain as independent as they wanted.
“People were encouraged and supported by staff to be as independent as they wanted to be.” from the report
Open management
Staff said managers listened and supported them. Regular meetings helped share learning, concerns and ideas for improvement.
“Staff meetings were held monthly and helped to share learning and best practice so staff understood what was expected of them.” from the report
Safeguarding contact details
needs fixingPeople and staff did not initially have local authority contact details readily available for reporting concerns directly. The manager put the details in place during the inspection.
“However, we found people using the service and staff did not have the contact details for the local authority readily available should they need to contact them directly.” from the report
Training renewals
needs fixingSome staff training was due for renewal or had expired. The manager said training had been booked and was being supported by the provider.
“We noted some training was due for renewal or had expired.” from the report
Delayed staff supervision
needs fixingSome staff supervision had not been completed in line with the provider's policy. The manager said new team leaders would help make supervision more consistent.
“We noted some staff supervision's had not been completed in line with the provider's policy.” from the report
Fire risk assessment
needs fixingThe fire risk assessment was due at the time of the inspection. The manager arranged a date for it to be completed.
“We noted a fire risk assessment was due.” from the report
- 01Has the fire risk assessment that was due at the inspection now been completed, and were any actions identified?
- 02Have all staff completed or renewed the training that was overdue or expired at the inspection?
- 03How are staff supervisions now monitored to make sure they happen in line with the provider's policy?
- 04Are local authority safeguarding contact details clearly available to people, staff and visitors?
- 05How are staffing levels being maintained while the ongoing recruitment exercise continues?
This was a comprehensive, unannounced first inspection under the current provider, covering all five CQC areas and resulting in Good ratings for each. This explanation was written from the published report of 28 February 2018 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
2 rated inspections over 6 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2018GoodSafe: 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.
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