We inspected Tudor Grange on 17 September 2018. The service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Tudor Grange is registered to accommodate up to 33 older people with varying support needs, and people living with dementia. On the day of our inspection there were 26 people living at the service.

Tudor Grange is required to have 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 home is run. The registered manager was present during the day of our inspection.

At our last inspection, on 1 August 2017 we rated the service as ‘Requires Improvement’. The service did not fully meet the fundamental care standards and was found to be in breach of Regulation 12 HSCA RA Regulations 2014 Safe care and treatment. This was because people who used the service were not protected against the risks associated with their care and support. Risk assessments did not fully include the information required to mitigate risks. People were also not protected from risks associated with the environment and medicines were not always administered safely and as required. The provider sent us an action plan informing us what action they planned to make and told us this would be completed by 31 October 2017.

At this inspection, we found the provider had taken the required action and the breach in regulation had been met. Whilst improvements had been made, further time was required for these to be fully imbedded and to ensure the sustainability of the improvements made.

Since our last inspection, improvements had been made to ensure people were protected from known risks. Staff had better guidance to support them to manage risks associated with people’s needs. Some improvements had been made to the environment with the completion of refurbishment work. Environmental checks on health and safety were not all up to date, but this was being addressed.

Since our last inspection, improvements had been made to the management of people’s medicines, but further work was required to ensure medicines were consistently and effectively managed. This included photographs for all people receiving support to manage their medicines and protocols, for medicines prescribed to be taken ‘as and when required’.

Staffing levels were sufficient on the day of the inspection, but concerns were identified in the deployment of staff. Communal areas were not always monitored leaving people at potential risk. Safe recruitment practices were followed.

Safeguarding procedures were in place to inform staff of how to recognise and report safeguarding concerns. The environment was clean and hygienic and staff followed best practice guidance in the prevention and control of cross contamination.

People had received an assessment of their needs that also considered their protected characteristics under the Equality Act, to ensure they did not experience any form of discrimination.

Staff received an induction and ongoing training and support, to enable them to provide effective care and support. Staff were positive about the training they had received and support from the registered manager.

People received sufficient to eat and drink. People’s preferences and nutritional needs were known and understood by staff and they received a choice of meals and were complimentary of the menu offered.

People’s health needs were assessed, planned for and monitored. Staff worked with external health care professionals to support people with their health needs. The service received weekly GP visits to su

The inspection took place on 1 August 2017 and was unannounced. The service was last inspected in January 2016 and was rated 'Good' overall. The inspection was brought forward due to some concerns we had received about how risks were managed.

The service is registered to provide accommodation with personal care for up to 33 older people with varying support needs, and people living with dementia. On the day of our inspection there were 27 people living at the service.

Tudor Grange is required to have 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 home is run. At the time of our inspection a registered manager was in place and had been registered since September 2016.

Systems in place to reduce the risks associated with people’s care and support were not always effective. People were not protected from risks associated with the environment. People could not be assured that they received their medicines as prescribed. Concerns were identified with the staffing levels provided that these were insufficient in meeting people’s individual needs and safety. Immediate action was taken to increase staffing levels. People felt safe and staff were aware of safeguarding policies and procedures. Safe staff recruitment procedures were in place and followed.

Staff received an induction but said they struggled to find time to complete refresher training. Staff did not always receive suitable training or support to enable them carry out their duties effectively and meet people’s individual needs.

People’s rights under the Mental Capacity Act (2005) were not respected at all times. In addition, people could not be assured that they would be supported in the least restrictive way possible. Where people had capacity they were enabled to make decisions and their choices were respected.

People were positive about the food choices and had their hydration and nutritional needs assessed and planned for. People had access to healthcare and their health needs were monitored and responded to.

Staff were kind, caring and compassionate and had a good understanding of what was important to people living at the service. People felt involved with making choices relating to their care and were supported to maintain their independence. People were supported to maintain relationships with family and visitors were welcomed into the service.

People could not be assured that they would receive the support they required as care plans did not always contain accurate, up to date information. People were happy with the activities and opportunities available.

People and relatives were unsure of the complaints procedure and who and how, to report concerns to. Opportunities were available for people and their relatives to share their experience of the service.

People and relatives were not all sure who the registered manager was and staff felt there was poor leadership of the service and that they were unsupported.

Systems in place to monitor and improve the quality and safety of the service were not as effective as it could have been. However, an improvement plan was in place to address some areas of the service.

During this inspection we found concerns relating to the safe care and treatment of people and this was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

This inspection was carried out by one inspector. At the time of our inspection there were 28 people living at Tudor Grange. We spoke with five people receiving care, the manager, a senior carer and two care staff working at the service. We spoke with a health professional who was visiting the home on the day of our inspection.They told us they had worked with the home for a number of years and we were able to discuss their experiences of the care provided at Tudor Grange. We asked people about their experience of the care they received. We spoke with a relative who was visiting on the day of our inspection. We also examined care plans and other records.

We last inspected this service on 25 November 2014. At this inspection we found people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not always maintained. At this inspection we found the service had made improvements to their record keeping. Care staff told us they had received further training and support. The home manager said they regularly audited the completion of records and care staff had developed a way of recording relevant information in care plans taken from the person’s daily records. A summary of what we found is set out below. We used the evidence we collected during our inspection to answer five questions.

Is the service safe?

One person who used the service told us they had moved downstairs because they were at risk of falling and increasingly unable to use the lift for moving between floors. Another person said, “I feel safe here I started falling last year at home and broke my hip and would be frightened of falling again."

We spoke with a healthcare professional who was visiting someone in the home. They told us they had been visiting the home for several years. They said they had no concerns about the quality of care people received. They said they visited the home most days to see people and they thought the standards of care were good.

We spoke with three care staff who understood how to protect people who received care from abuse or neglect. Care staff told us they wanted to ensure people received safe, effective care.

We saw individual evacuation plans were posted inside each person’s room. These identified the level of support the person needed to evacuate the building in an emergency, for example a fire.

There were no Deprivation of Liberty Safeguards (DoLS) in place at the time of our inspection. The Deprivation of Liberty Safeguards are a legal framework designed to ensure that the care people receive does not unlawfully deprive someone of their liberty. Care staff we spoke had received training in the Mental Capacity Act (2005) and were knowledgeable about the process required for assessing a person's mental capacity and making decisions in their best interest.

Is the service effective?

The visiting healthcare professional we spoke with told us the home provided effective support for people at the end of life. They said when they had been involved in end of life care planning people usually expressed a preference to stay in the home rather than be admitted to hospital. They said care staff were good at contacting them to obtain advice and acting on it. We found people's needs had been assessed and care plans were reviewed monthly. Care staff reviewed the support provided and identified if any changes to care plans were needed. Risk assessments had been carried out and were reviewed. Care was adjusted if a person’s condition meant they required more support.

We found care staff had the appropriate training and experience to enable them to carry out their role effectively. Care staff told us they received regular supervision and appraisal. Care staff training was up to date.

Is the service caring?

We spoke with three people who used the service who told us care staff were considerate and respectful. One person said, “I feel at home here and I know people will help me if I need help." We observed staff supporting people to eat their lunch. One person we spoke with told us they had previously stayed in another home but they thought the staff here were more helpful and caring. A relative we spoke with told us, "Staff really seems to care about people."

Some people told us they liked to spend time in their room and we found care staff visited them often to check if they needed a drink or to be re-positioned if they were in bed.

The service had carried out a survey of people’s views about the service in 2014 which showed that 80% of the people who responded were happy with the support provided by care staff.

Is the service responsive?

On the day of our inspection the manager told us they were concerned about one person who was experiencing pain. Care staff had called the person’s GP who agreed to issue a new prescription. We saw care staff had gone to collect the person’s medicine which arrived a short time later.

We asked one person how responsive care staff were if they pressed the call assistance alarm. The person told us, “I have sometimes had to wait for a while for anyone to come through the night but the last few times it has been much better. During the day it is fine.”

We spoke with one person who had brought their pet to live with them in the home. The person told us they were really pleased they could bring their pet with them to provide company and enable them to get out in the fresh air.

Is the service well-led?

Care staff told us their manager was supportive and approachable. The provider had systems in place to assess and monitor the service. The manager completed a number of monthly reports to the provider’s head office. This included audits of people’s care plans. Records showed managers from the provider’s head office visited the home and audited care plans.

At our previous inspection we found that people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not always maintained. At this inspection we found the service had made improvements to their systems of record keeping.

The service carried out checks of equipment for moving and transferring people, for example, hoists. Arrangements were in a place for checking fire safety equipment and for protecting people in the event of a fire.

The views of people who used the service were sought and the manager had written to people and their relatives to inform them of the results. People were then informed about the actions the service intended to take based on the outcome of the survey.

We spoke with two people who used the service regarding their care. One person said, “Staff are patient and are mainly helpful.” Another person said, “I love living here. I can do what I like. The staff are kind and look after me.”

We found that people were being respected and involved in their care. We found improvements in the way care and treatment was planned. We also found care and treatment was delivered in a way that was intended to ensure people’s safety and welfare.

We found that the provider was ensuring that there was sufficient equipment available and that it was safe to use. We found improvements in the way staff were recruited to ensure they were safe to work with vulnerable people.

However, we found the care records confusing and were concerned with their accuracy and consistency.

People told us that staff members obtained their consent before supporting them with care or treatment. Care records recorded which decisions people were able to make for themselves and which decisions they did not have the capacity to make.

People received the care and support they required to improve their health and well-being. However, care records were not written in enough detail to provide clear guidance to staff members, and reviews of care plans did not always evaluate the care provided and whether it was effective.

People were provided with a choice of meals and staff members assisted them appropriately with eating and drinking if this was required. They told us that their meals were always very nice.

Medicines were stored appropriately and records were maintained to show all storage areas were kept at the correct temperature. Administration records were kept and people received their medicines in a safe way.

Recruitment checks were all carried out or obtained prior to new staff members starting work with the service.

The service had a policy and procedure to guide people in how to make a complaint and information about taking complaints further. People told us they were able to make a complaint and that it would be dealt with.

We carried out this responsive inspection because we had concerns that this service had not been visited since 2007.

One person told us, “I visited the home a number of times before I decided to live at the home. I was always made to feel welcome and that’s why I decided to choose this care home.”

Another person told us, “Monthly meetings are held for people who live here and we usually have our say if we want to.”

People who use services told us that they felt safe living at the home and that the regular staff treated them well.

We asked three people if they felt that there were sufficient staff employed at the home to meet their needs, comments included, “Yes usually, and our regular staff are very good.”

One person told us, “Recently agency staff have been used at night and I am not keen on some of them.”

We inspected the service on 6 January and 7 January 2016. Tudor Grange is registered to provide accommodation and personal care for up to 33 older people living with or without dementia. On the day of our inspection there were 28 people living at the home.

The home had a manager who was on duty on both days of the inspection. They had managed the home since November 2015 and were in the process of registering with us. 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, and their representatives, felt safe and well looked after at Tudor Grange. People told us that staff met their needs effectively and were all kind and caring. Staff were knowledgeable about people’s needs, preferences and life experiences. Staff respected people’s privacy and dignity.

Staff had a good understanding of what constituted abuse and would be confident to recognise and report it. Staff felt that people were kept safe.

Some maintenance issues relating to keeping the environment safe in the event of a fire had been identified by the provider but not actioned. The manager was following this up. The home’s smoking policy required review in light of arrangements within the home to ensure people’s ongoing safety at all times.

Although staffing levels reflected numbers assessed based on dependency staff were rushed and this impacted on their ability to respond to needs promptly. The manager was in the process of reviewing staffing levels.

Staff were recruited through safe recruitment practices and overall medicines were stored and administered safely.

Staff received appropriate training and supervision. There was an induction program in place to support new staff. Staff were positive about the support and training they received. Staff understood their roles and responsibilities and said that they had good training opportunities. The manager was actively looking for alternative training methods to support the on line learning that staff were required to complete.

People’s rights were being protected under the Mental Capacity Act 2005.The manager and staff team were in the process of developing their knowledge and understanding of the legislation so that they could carry out their responsibilities effectively.

People were provided with sufficient food and drink to maintain their good health and wellbeing, and overall people were satisfied with what they had to eat. Health professionals worked closely with the home to ensure people’s health care needs were met. Communication between staff and outside agencies was good.

Overall people enjoyed a range of activities both at the home and in the community.

People and their relatives were involved, or had opportunities to be involved, in the development and review of the service. People felt listened to and would be confident to make a complaint or raise a concern if they needed to. Staff knew the complaints procedure and we saw outside agencies had supported people with decision making when appropriate. People who used the service and the staff team had opportunities to be involved in discussions about the running of the home and felt the management team provided good leadership. There were systems in place to monitor the quality of the service provided.