Tudor Cottage is registered to provide accommodation with personal care for up to 19 older people, who have become frail, are living with dementia or who require respite or end of life care. 15 people lived at Tudor Cottage when we visited.

This unannounced comprehensive inspection took place on 17 and 18 August 2017. This inspection was to follow up to see whether improvements had been made and ensure the provider had maintained standards in other areas.

Previously on 7 February 2017, in response to concerns raised, we inspected the service and looked at the safe and well-led domains. At that inspection we found some people’s risk assessments did not identify all risks, or adequately assess and manage how people’s individual behaviours might impact on their safety and wellbeing or safety of others and staff. Further improvements were also needed in record keeping and in team working. Although no breaches of regulations were found, both domains were rated as requires improvement.

Prior to that on the 17 and 18 December 2015 we carried out a comprehensive inspection. At that inspection, the service was rated ‘Good’ overall and in each of the safe, effective, caring, responsive and well led domains.

The service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service had worked with the local authority quality improvement team to make the required improvements.

People's risk assessments were more comprehensive with actions taken to reduce the risks as much as possible. Staff demonstrated a good awareness of each person's safety and how to minimise risks for them. Accidents and incidents were reported and included measures to continually improve practice and reduce the risks of recurrence. Staff understood the signs of abuse and knew how to report concerns, including reporting to external agencies. They had completed safeguarding training and had regular updates. A detailed recruitment process was in place to ensure people were cared for by suitable staff. People received their medicines safely and on time from staff that were trained and assessed to manage medicines safely.

People received a good standard of care because the management team set high expectations of the standards of care expected. There was a clear management structure in place, staff understood their roles and responsibilities and felt valued for their contribution. Staff had the knowledge and skills needed to carry out their role.

Staff developed positive, kind and compassionate relationships with people. People appeared happy and content in their surroundings and were relaxed and comfortable with staff who were attuned to their needs. The service had enough staff to support people's care flexibly around their wishes and preferences. People's care was individualised, staff knew people well and treated them with dignity and respect. Significant improvements had been made in the variety of group and personalised activities for people living at the home with an increased focus on social contact and companionship.

People experienced effective care that promoted their health and wellbeing. People praised the quality of food and were supported to improve their health through good nutrition. People had access to healthcare services, staff recognised when a person's health deteriorated and sought medical advice promptly.

People's rights and choices were promoted and respected. Staff understood the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards; they involved the person, family members and other professionals in 'best interest' decision making.

Care records had improved and further improvements were being made. People k

We completed an unannounced inspection on 7 February 2017 in response to receiving information of concern about the standard of care provided to people at the home. The concerns primarily related to three staff and an agency worker, who had previously worked at the home. This report only covers our findings in relation to these concerns.

We previously carried out a comprehensive inspection at the service on the 17 and 18 December 2015. At that inspection, we found no breaches of regulations. The service was rated ‘Good’ overall and in each of the safe, effective, caring, responsive and well led domains. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Tudor Cottage on our website at www.cqc.org.uk

Tudor Cottage is registered to provide accommodation with personal care for up to 19 older people, who have become frail, are living with dementia or who require respite or palliative care.

The service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

On 30 January 2017, concerns were first raised to the Care Quality Commission (CQC). They included allegations about poor standards of practice, about attitudes of three staff working at the home and about an agency worker who had previously worked at the home. The person who had contacted us was concerned about the safety and wellbeing of eight people in particular. We raised a safeguarding alert to the local authority safeguarding team about those people. We also contacted the district nursing team who visited the home regularly for feedback, who had no current concerns about the service. Following this, a second person contacted CQC and the local authority safeguarding team with similar concerns. As the concerns included allegations the manager failed to take appropriate action in response to some specific concerns, the safeguarding team contacted the provider and asked them to investigate the concerns.

Most people said they were happy living at the home and felt safe living there and we had no concerns about staff interactions with people when we visited. However, one person we spoke with raised some concerns. The person had told the provider about this, which they confirmed they were aware of.

People knew how to raise concerns and were confident any concerns would be listened and responded to. Staff were knowledgeable about people’s care needs, although some areas for improvement were identified in relation to one person’s risk assessments and care plans. Staff were aware of signs of abuse and knew how to report concerns.

The provider undertook a detailed investigation and provided a written report to the CQC and the local authority safeguarding team. They interviewed people who lived at the home and some relatives and staff working at the home including the registered manager. The provider’s report showed the investigation was hampered because there was a lack of information about dates and time certain incidents were alleged to have taken place, and a lack of records related to them.

The provider’s report showed most people were happy living at the home and had no major concerns. Most staff were also happy working at the home and felt well supported. Most of the allegations could not be proven. Some concerns about an agency worker who previously worked at the home were upheld and had already been reported to the agency that employed them for further action. The report also confirmed a person did not receive breakfast on one occasion. It also identified some misunderstandings and miscommunication within the staff team about practice, which the provider planned to address.

The report showed the provider t

We spoke with five people who lived at the home, the proprietor, home manager, a senior support worker, and support staff. We also spoke with four relatives who were visiting. All five people told us that they were happy with the care and support they received. One said “They look after me here.” Another said “Staff here look after us well.”

All of the relatives told us that they were satisfied with the care and support their relative received. One told us “They’re really good in here.” Another relative said “It’s really good here, we are really pleased. It has a very good reputation locally.”

We found that people had comprehensive care plan files, which contained lots of information on how people wanted to be supported, and what they were able to contribute themselves. This meant support staff could be clear about what type of support a person needed, their choices and preferences, and which parts of tasks they were able to do for themselves.

The home is an older listed building and in places had low ceilings and numerous corridors to rooms. We saw that in places protective foam had been fitted to particularly low door frames and warning signs were on display. One person and a relative told us they sometimes had difficulty with the uneven floors; however two relatives told us that they felt the character of the home made it feel like “coming to someone’s house” and that their relative liked it and found it “very cosy.”

Whilst at the service we heard and saw staff talking with people and offering them choice and support in a respectful and positive way.

We observed that people who used the service were well supported with their needs met with dignity and respect. We looked at people's care plans, personal care, health care needs, risk assessments and day and night routines and found that they encompassed the safety and well-being of people who used the service. We saw that mental capacity assessments regarding the best interest of the people who used the service had been completed. Four of the best interest assessment records we reviewed relating to medication not been signed by the person using the service their relative or their representative.

Staff and representatives said that they knew how to raise a concern or make a complaint. There were policies and procedures in place providing guidance and all staff had received safeguarding training which were identified on the training matrix.

Staff told us they were supported by management and that they received regular training. We saw that staff were supervised regularly and were appraised annually. The quality of the service was monitored at local and provider level through regular spot checks. People who used the service and representatives were provided with the opportunity to give feedback regarding the running of the service.

The inspection took place on the 17 and 18 December 2015 and was unannounced. We previously inspected the service in January 2014 and found the service was compliant with the standards we looked at and there were no breaches of regulations.

Tudor Cottage is registered to provide accommodation with personal care for up to 19 older people, who have become frail, are living with dementia or who require respite or palliative care.

12 people lived there when we visited and we met all of them. It is also registered to provide personal care for people in their own homes but this service was dormant when the inspection took place. The provider had notified us about this.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People who used the service, relatives and health and social care professionals gave us positive feedback about the service. People were treated with dignity and respect and staff were caring and compassionate towards them.

Staff knew each person as an individual and what mattered to them. The service was organised around people’s needs and wishes. Staff documented detailed life histories about each person, their life and family before they came to live at the home

People experienced care and support that promoted their health and wellbeing. They received effective care, based on evidence based practice, from staff that had the knowledge and skills needed to carry out their role. Health and social care professionals gave us positive feedback about the care and support provided for people.

Each person’s care needs were assessed and care records had information about how to meet those needs. Care was focused on people’s individual needs, wishes and preferences and people were supported to remain active and independent. People were supported to express their views and were involved in decision making about their care.

People were offered day to day choices. Staff sought people’s consent for care and treatment and ensured they were supported to make as many decisions as possible. Where people lacked capacity, staff confidently followed the Mental Capacity Act 2005 and its code of practice. People’s capacity to make day to day decisions was assessed. Where people lacked capacity relatives, friends and professionals were involved in best interest decision making.

People praised the quality of food and choices available at the home. Staff supported people with poor appetites who needed encouragement to eat and drink, to stay healthy and avoid malnutrition and dehydration.

People said they felt safe living at the home. Staff were aware of signs of abuse and knew how to report concerns; any concerns reported were investigated. A robust recruitment process was in place to make sure people were cared for by suitable staff. People knew how to raise concerns and were confident any concerns would be listened and responded to. The service had a written complaints process. Any concerns or complaints were investigated with actions identified to make improvements.

People, relatives and staff said the home was organised and well run. The culture was open and honest. Staff worked well as a team and felt supported and valued for their work. Senior staff acted as role models to support staff to achieve high standards of care.

The provider had a range of quality monitoring systems in place, which were well established. There was evidence of making continuous improvements in response to people’s feedback, the findings of audits, and of learning lessons following accidents and incidents.

The care environment was adapted to meet the needs of people living there. People were assisted to identify key areas such as toilets and bathrooms independently. This was because they were well signposted to help people find them.