About the service: Tudor Lodge is a large detached house in a quiet residential area. It provides care and support for up to 44 older people some of whom are living with dementia. There were 34 people living at the service when we inspected.

People’s experience of using this service:

At our last inspection in November 2017 we identified that some people did not always receive the support they needed at mealtimes; we observed that people’s privacy and dignity was not always upheld; risks around some people’s safety had not been assessed. Records were not always accurate or accessible and systems for assessing and monitoring service quality were not robust. The provider told us what action they would take to improve this.

At this inspection we found that there had been progress and improvement in many areas and most of the previous breaches in regulation met. We found however that medicines were not being managed safely and have issued a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Although strengthened the system to assess, monitor and improve the service and improvements to the accuracy and completion of records had not fully met the previous breach Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 has not been fully met and further improvements are needed

Since the last inspection there was a new registered manager, she had worked hard to change the culture within the service and address previous shortfalls, as a consequence there had been a complete turnover of staff. This was enabling the registered manager to develop a new team and culture within the service. Staff thought communication was good between staff and that there were good working relationships. The provider acknowledged further work was needed and had already identified further improvements to be made from within their own service development action plans. This included for example team building, record keeping, and improving the type and range of activities and stimulation for people in the service. Overall staff told us that they enjoyed where they worked and were committed to providing people with good quality care.

People and relatives spoke positively about service quality. People told us that they felt safe and well cared for. Relatives felt reassured that their relative was living in a safe place where their needs were taken care of. Relatives told us that they had found communication from staff to be good and the registered manager approachable. People and relatives told us that staff were caring and took time to get to know people well. People and relatives told us that they had no concerns but felt able to raise them if they did and were confident these would be acted upon.

We observed that there were enough staff to support people’s needs during the day, the provider agreed to relook at morning availability of staff which had been highlighted by some staff as a particularly busy time.

A full range of checks were made of new staff to help ensure people were supported by suitable staff.

Staff were provided with an appropriate programme of training to understand and support people’s individual needs. They demonstrated a detailed knowledge of people and their routines and preferences.

People lived in a safe well-maintained environment where equipment was routinely serviced and checked that in was in safe working order.

Improvement recommendations made by the fire service were being addressed to ensure they met the required standard of fire safety.

Peoples health needs were supported. Health professionals visiting to provide routine health care support raised no concerns about the appropriateness of referrals to their service; they said staff followed advice and guidance appropriately in support of people’s health needs.

Staff felt confident of raising issues with senior staff and felt supported, they had opportunities to express their vi

This unannounced inspection was carried out on 23 November 2017. The inspection was a focused inspection because of concerns received about the service. We looked at Safe and Well Led domains during this visit. We decided to go back to the service on 27 November 2017 to get a full picture and inspected the Effective, Caring and Responsive domains which turned the inspection into a full comprehensive inspection.

At the last inspection on 12 October 2017 the service was overall rated as Good.

At this inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also made two recommendations in relation to good practice. You can see what action we told the provider to take at the back of the full version of this report.

Tudor Lodge is a ‘care home’. People in this care home receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Tudor Lodge accommodates up to 44 older people some of whom are living with dementia. There were 40 people living at the service when we inspected.

The service was run by a registered manager and they were present on the days of our visit. ‘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 and their relatives told us staff were kind and caring and made people feel safe. They said staff had the necessary skills to respond to people’s needs, monitored their health and that people enjoyed their meals.

Staff sought and received people's consent to the support they provided and in line with the principles of the Mental Capacity Act 2005. CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The service had made DoLS applications, to ensure that people were only deprived of their liberty, when it had been assessed as lawful to do so

People’s needs were assessed and a plan of care was developed which included their choices and preferences, but was not always person centred and accurate.

There was inconsistency in staff practice which meant that people’s dignity was not always respected.

People’s health needs were assessed and monitored and the service worked in partnership with healthcare professionals to ensure people received appropriate care and treatment. However, there were examples where the provider had not effectively managed and responded to risk.

Medicines were managed safely and people received them as prescribed.

Recruitment practices were robust in ensuring only suitable staff were employed at the service.

Staff training was on-going and plans were in place to ensure they received relevant training for their role. Staff felt well supported both informally and through formal processes such as staff meetings and supervisions.

Management systems were in use to minimise the risks from the spread of infection and keep the service clean, although records did not always support this.

We have made recommendations about the deployment of staff to ensure they are available in suitable numbers to meet the needs of people living with dementia; adaptation to the environment to support independence of people living with dementia; and promoting activities and stimulation to meet the needs of all the people at the service.

Systems to monitor the quality of care were not effective. Potential risks were not always accurately monitored and recorded and records were not always accurate which could result in people receiving inappropriate staff support.

The views of people and their relatives were sought through meetings and an annual survey.

The inspection took place on 12 October 2017 and was unannounced.

Tudor Lodge is a large detached house in a quiet residential area. It provides care and support for up to 44 older people some of whom are living with dementia. There were 38 people living at the service when we inspected.

The service had 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. This is the first inspection since a change to the providers registration in October 2016.

People, relatives and health professionals told us that people were safe at the service. People were supported by staff who had received safeguarding training and understood their responsibilities in keeping people safe from harm. The registered manager had contacted the local authority safeguarding team when required and had taken action to keep people safe. Risks to people were identified and assessed. Plans were put in place to minimise risks and gave staff the guidance they needed to mitigate risks. People’s medicines were managed by trained staff and people were supported to be involved as they wished. Some people at the service chose to manage their own medicines and they were supported to do this safely.

People were supported by staff who told us they had the training and support they required to meet people’s needs. There was a schedule of training in place which included competency assessments. Some staff had begun additional training to become a ‘champion’ in areas such as dignity or dementia. Health professionals told us the staff were “on the ball and knew how to care for the people who live at the service.” Staff had regular meetings and one to one supervisions with their line manager. The registered manager used a dependency tool to identify how many staff were needed on duty. There were enough staff to meet people’s needs and people told us, “There is always someone nearby if you need help.” Staff were recruited safely, checks were carried out to ensure they were suitable for their role before they began working at the service.

People are supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff asked for people’s consent before giving support and explained to people what was happening. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. The registered manager had applied for DoLS when required.

People were supported by staff who knew them well and treated them with dignity and respect. Staff treated people as individuals and adapted their interactions to meet each person’s needs and preferences. Staff told us about people’s lives before they lived at the service and the activities they enjoyed the most. People’s care plans were person centred and gave staff the guidance they needed to know what people could do for themselves and when they needed support. Care plans included life histories and small details about people’s preferences, for example how they like their room at night or their favourite fragrance. People and their relatives told us they were involved in planning and reviewing their care on a regular basis. People were supported to remain as independent as possible. On the day of the inspection several people went out independently.

People took part in range of activities based on their interests and hobbies and there was an activities co-ordinator at the service. One person said, “There is always something going on if you want to join in.” Activities were displayed in an accessible format using pictures. There was also a pictorial menu board showing peop