CQC report explained · a residential care home
What the CQC found at Tudor Manor
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2023
Rated Inadequate and placed in special measures; inspectors found serious safety, safeguarding and management failures.
This was an unannounced focused inspection on 1 and 2 August 2023. Inspectors spoke with people, relatives, staff and a visiting professional. They reviewed care records, medicines records, staff recruitment files and management records.
The inspectors found people were at risk because risks were not consistently assessed or managed. Problems included faulty call bells, weak fire safety arrangements, incomplete care plans, missed safeguarding notifications and unsafe recruitment checks. Records for repositioning, bowel monitoring and some health conditions were incomplete.
The home was rated Inadequate overall. Safe and well-led were rated Inadequate. Effective and responsive were rated Requires Improvement. The Caring rating was not reviewed during this focused inspection.
Medicines usually given as prescribed
Inspectors found that people received their medicines safely and as prescribed. Improvements had also been made to protocols for medicines given when needed.
“People received their medications safely and as prescribed.” from the report
Food choices
People were supported to eat and drink. They could choose meals and request an alternative if they did not want the planned option.
“People told us they were offered alternative meals if they didn't want meal choices on the menu.” from the report
Contact with relatives
Relatives and friends were able to visit, and the home supported people to maintain contact with loved ones.
“People were supported to maintain contact with their loved ones.” from the report
Partnership working
Staff worked with outside professionals to support people's care, although inspectors found that concerns and professional advice were not always handled promptly or consistently.
“Staff worked with other external professionals to ensure people received a joined-up approach to their care.” from the report
Risks and fire safety
seriousRisks were not consistently assessed or reduced. A second-floor call bell system was not working correctly, fire safety actions had not been followed up, and a fire door was blocked.
“Risks to people were not consistently assessed, nor measures put in to place to mitigate the risk to people.” from the report
Safeguarding failures
seriousFour incidents involving harm had not been reported to the CQC or the local safeguarding team. The provider submitted past notifications during the inspection.
“We identified 4 incidents where people had sustained harm that had not been reported to the Care Quality Commission or the local safeguarding team.” from the report
Consent and mental capacity
seriousCapacity assessments and best-interest decisions were missing in some cases. Inspectors also saw staff enter bedrooms without knocking or seeking consent.
“This put people at risk of being deprived of their liberty unlawfully.” from the report
Unsafe recruitment
seriousSome staff files lacked required references. One person started work before their DBS certificate was returned, and checks from previous employment were not properly confirmed.
“Staff were not recruited safely, this put people at risk of receiving care and support from unsuitable staff.” from the report
Weak management oversight
seriousThe home had no effective audits for daily care, medicines, staffing, recruitment or other safety matters. The provider had not resolved issues identified at the previous inspection.
“At this inspection, we found no improvements had been made.” from the report
- 01What immediate action has been taken to make call bells, fire arrangements and evacuation plans safe?
- 02How are safeguarding incidents now reported to the CQC and the local safeguarding team?
- 03Which care plans and risk assessments have been completed for diabetes, repositioning, bowel monitoring, self-neglect and behaviour?
- 04How are mental capacity assessments, best-interest decisions and DoLS applications now recorded and checked?
- 05What audits are now in place to monitor daily care, medicines, staffing, recruitment and incident learning?
This was a focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected and the report says ratings for uninspected questions carry over from the previous inspection. This explanation was written from the published report of 11 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 2022
Tudor Manor was rated Requires Improvement; inspectors found kind care, but safety checks, medicines monitoring and management systems needed improvement.
This was an unannounced focused inspection on 14 December 2021. Inspectors reviewed Safe, Effective and Well-led, following concerns about infection control, training, medicines, building maintenance and recruitment. They spoke with people, relatives, staff and health and social care professionals, and reviewed care, medicines, recruitment and management records.
The home was clean and well maintained, with enough staff to meet people's needs. People and relatives said they felt safe and spoke positively about staff. However, some radiator covers, bedroom door locks and window restrictors were not safe or up to the required standards. Three medicine doses had been missed because stock had run out, and there was no guidance for some as-required medicines.
The provider's checks had not always found or dealt with risks quickly enough. This included building safety, medicine stocks and staff following face-covering guidance. The home was rated Requires Improvement overall, with Safe and Well-led also Requires Improvement. Effective was rated Good.
Kind and reassuring care
People and relatives said they felt safe and were positive about the staff. Inspectors observed kind interactions.
“People we spoke with told us they felt safe from the risk of abuse.” from the report
Enough staff
Inspectors found staffing levels met people's identified needs. Recruitment checks were mostly in place, although some references and employment gaps needed more attention.
“Our observations during the day indicated there were enough staff on duty to meet people's identified needs.” from the report
Good health and nutrition support
People's dietary requirements were met, and staff monitored health needs and involved healthcare professionals.
“Health and social care professionals confirmed the service worked in partnership with them to maintain people's health and support needs.” from the report
Staff support and consent
Staff received supervision, training and handovers. Inspectors saw staff seek consent and found mental capacity assessments were decision-specific and in people's best interests.
“We heard staff seek people's consent before carrying out support.” from the report
Building safety risks
seriousSome bedroom door locks and window restrictors did not meet the required standards. Two windows could be opened fully, and radiator covers had not been fitted promptly.
“Checks had not identified window restrictors were not compliant with Health and Safety guidance and two windows had no restrictors in place and could be opened fully.” from the report
Missed medicines
seriousOne person's medicine ran out, resulting in three missed doses. The home also lacked protocols explaining when some as-required medicines should be given.
“We checked their medication records and three doses had been missed because the medication had run out.” from the report
Weak management checks
seriousThe provider's audits did not identify or resolve several risks quickly enough. This led to a breach of Regulation 17.
“The provider had failed to ensure there were effective governance systems in place to identify concerns and drive timely improvements.” from the report
Past face-covering guidance
needs fixingStaff did not wear face coverings between August and November 2021 because the provider had misunderstood the government guidance. Inspectors found staff were following the latest guidance at the inspection.
“We had received information staff members had not been wearing face coverings between August 2021 and November 2021.” from the report
- 01What has been done to replace the bedroom door locks and window restrictors, and how has this been checked against the required safety standards?
- 02How do you now monitor medicine stock so that medicines do not run out?
- 03What written protocols are in place for people's as-required medicines, including pain relief?
- 04What changes have been made to the provider's audits so that building and medicine risks are identified and fixed promptly?
- 05What action plan was sent to CQC, and what progress has been made since the inspection?
This was a focused inspection of Safe, Effective and Well-led following concerns; Caring and Responsive were not inspected, and their previous ratings were carried over. This explanation was written from the published report of 11 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.
Every inspection of Tudor Manor
4 rated inspections over 8 years: the service has slipped, from Good to Inadequate.
- November 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- February 2022Requires improvementdown from GoodSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- November 2018Goodstayed GoodSafe: GoodEffective: GoodResponsive: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 22 February 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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