This inspection took place on 19 and 30 July 2018 and was unannounced.

Tudor House is registered to provide residential and nursing care for up to 30 older people who may be living with a physical disability or dementia. The service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The service is a converted town house with accommodation provided across two floors. At the time of our inspection there were 25 mainly older people using the service.

At the time of our inspection, the previous registered manager had not yet deregistered although they were no longer managing the service. The service had a new manager who had been in charge since October 2017. They were in the process of registering with the CQC to become the registered manager. A registered manager is a person who has registered with the CQC 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 manager was also the registered manager for another of the provider’s services and split their time between managing the two homes. They were supported by a deputy manager and nurses in the management of Tudor House.

At the last inspection in May 2017, we rated the service requires improvement overall and identified two breaches of regulation relating to safe care and treatment and the governance of the service. This was because staff training was not up-to-date and regular fire drills had not been completed. There were gaps in care records and limited activities took place when the activity co-ordinator was not at work. Quality monitoring systems had failed to identify and address these concerns. We asked the provider to take action to address our concerns.

At this inspection, we identified some improvements had been made and the provider was compliant with the regulation relating to safe care and treatment. However, we identified a number of new issues and ongoing concerns about the governance of the service.

Staff were not always effectively deployed and people were left unsupervised for long periods of time. People who used the service told us staff did not always respond quickly to their requests for assistance.

People told us there were not enough activities. The activities coordinator was not at work and the provider had not taken adequate steps to make sure regular and meaningful activities continued in their absence. We raised concerns at our last inspection about the lack of activities when the activities coordinator was not at work and found on-going concerns at this inspection.

Complete and contemporaneous records were not always in place. There were gaps in recruitment records. Profiles and induction records were not always available for agency staff. Accident and incidents records were incomplete and did not always evidence action taken to prevent similar things happening again.

The provider and manager completed a range of audits, however, these had not ensured portable appliance tests were completed in line with the provider's policies and procedures. Checks had not been consistently documented to evidence medicines were stored at a safe temperature. Annual medicine competency checks, designed to make sure staff were safe and competent administering medicines, were overdue.

Staff had not received regular supervisions at the frequency set out in the provider’s policy and procedure. Records did not evidence the support provided to new staff during their first months at the service.

There was a new breach of regulation relating to person-centred care and a continued breach of regulation relating to the governance of the service. Yo

We carried out a comprehensive inspection of this service on 11 March 2016. Breaches of legal requirements were found. Parts of the service were not clean. This meant people who were not protected from the risk of infections acquired and spread. In addition we found some care records had not been updated and there were gaps in care plans, which meant that staff did not always have the written guidance they needed to care for people. The provider’s systems to assess, monitor and improve the quality of the service were not always effective as they had not identified any of the issues we identified at inspection. At the inspection in March 2016 we rated the service as ‘Requires Improvement’.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook a further comprehensive inspection to check that they had followed their plan and to confirm that they now met legal requirements.

We inspected the service again on 23 May 2017. This was an unannounced inspection, which meant that the staff and provider did not know that we would be visiting. At this inspection we found the provider had followed their plan and legal requirements had been met. However, we identified different breaches of legal requirements and rated the service as ‘Requires Improvement’.

The home had 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.

Tudor House provides accommodation and nursing care to accommodate a maximum number of 30 older people, some of whom were living with a dementia.

Not all staff had not taken part in fire drills. Staff had not been provided with the training to ensure a person’s safe evacuation from the service in the event of fire.

Staff were not up to date with their training in fire safety, equality and diversity and emergency first aid. There were insufficient staff trained in emergency first aid to ensure that a trained staff member was on duty on all shifts.

There were systems in place to monitor and improve the quality of the service provided. However, this quality monitoring system had not detected the further areas we identified as requiring improvement.

Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety. Risks to people's safety had been assessed by staff.

There were sufficient staff on duty to meet the needs of people who used the service. We found that safe recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. This included obtaining references from previous employers to show staff employed were safe to work with people.

Appropriate systems were in place for the management of medicines so that people received their medicines safely.

Staff had an understanding of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards and acted in the best interest of people they supported. However, best interest decisions did not always record the views of family and professionals.

Menus provided people with a choice of healthy food and drinks, which helped to ensure that their nutritional needs were met. We received mixed feedback from people on the food provided.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff to hospital appointments.

There were positive interactions between people and staff. We saw that staff treated people with dignity and respect. Staff were kind and interacted well with people. Observation of the staff

This inspection took place on 4 March 2016 and was unannounced. The last inspection took place on 11 December 2013 and the service was meeting all of the regulations we assessed.

Tudor House, which is owned by Roche Healthcare Limited, is a care home registered to provide personal and nursing care for up to 30 people. Tudor House is a detached home with disabled access, a passenger lift to the first floor and car parking facilities. The service has three communal lounges on the ground floor, some bedrooms have ensuite access.

At the time of our inspection 25 people lived at the service.

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.

Parts of the service were not clean and there were areas where germs could collect, this meant that people who used the service were not being cared for in a pleasant environment and they were not protected from the risk of infections being acquired and spread. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Although people told us they received a good standard of care we saw some gaps in care records which meant people were at risk of receiving care which was not planned or based on their current needs. We saw some out of date information in care plans. Some other associated care records were not up to date and the audits the service used had not identified these issues and so they had not been rectified. This was a breach of Regulation 17 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.

The service had an up to date safeguarding policy and staff understood how to identify types of abuse and who they should report their concerns to. Risks assessments and risk management plans were in place to support people to remain safe. People were supported to take their medicines safely. The service sought support from relevant health care professionals when required.

The registered manager told us the service did not use a staff dependency tool but they assessed staffing levels on a regular basis. Overall we found there were sufficient staff. However, there was a period of time when people were not provided with supervision and they were unable to summon assistance from staff. This meant people were at risk of injury as staff were not available to assist people nor did they have a safe means of seeking assistance. We have made a recommendation about the deployment of staff.

People told us the food was good and we saw people’s individual dietary needs were met. For example some people needed support to eat and this was provided in a compassionate way.

Staff were well supported by the registered manager and had access to a variety of training.

The principles of the Mental Capacity Act 2005 were being followed. The registered manager explained updated assessment paperwork was being introduced. Staff consistently demonstrated they sought consent from people.

The service sought the views of people, relatives, staff and other relevant stakeholders. They used the feedback to make improvements to the service. People knew how to make complaints and the complaints policy was accessible. The registered manager told us they had an ‘open door’ policy and welcomed people’s feedback.

Activity and stimulation for people within the service was limited. Although the service employed an activity co-ordinator four days a week the rest of there was limited interaction for people. We have made a recommendation about ensuring activity and stimulation meets people’s individual needs.

Despite the short

We used a number of different methods to help us understand the experiences of people living at the home. We spoke with six people who lived at the home. We also spoke with seven relatives who were visiting the home. We found people looked well cared for and relatives told us they thought people were treated well and their experiences in the home were positive. We observed the care staff being kind and respectful to people. One relative told us, "I looked at two or three other places and decided this one was most comfortable and suited their needs, best."

We saw from people's care plans that people were supported to live as they chose to, within their limitations. Staff at the home had carried out an assessment of the needs of each person, and kept this under review. This helped to make sure appropriate care and support was given.

We looked at people's care records and saw arrangements were in place to identify and monitor those people at a greater risk of poor nutrition and dehydration.

People who lived at the home were protected from risks of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Staff we spoke with told us they received training which helped them to deliver care and support people safely.

The home had systems in place to make sure people were safely cared for. This included policies and procedures and quality monitoring systems.

We spoke with four people who lived at the home. They told us that the staff were kind and caring. They felt that they were able to say how they wanted to be cared for. One person said, “I’d recommend this place to anyone.”

We were told that the care staff are, “most kind” and that “everyone is approachable.”

The relatives we spoke with told us that they felt involved and supported by all of the care team. They felt the “manager was very good” she involved them and “always had time to listen.” We were told that the care provided at the home was good. One relative said of his wife, “she is in good hands.”

People told us that they felt safe here at Tudor House and that they would speak to the staff or the manager if they had any worries.

People felt that they were consulted and they were involved in decision making about their care. They told us that staff always asked for their consent to any treatment or care and that their care was explained to them so they understood what they were consenting to.

People thought the staff were respectful and supported them in a way that they preferred. “The staff are all very caring and ask me what I want to do, I do what I like, and sometimes I just watch TV all day, if I want to”.

People told us that they felt well cared for and safe in the home, “The care is tip top here”.