The inspection took place on 2 and 7 November 2018 and the first day was unannounced. At the last inspection of the service in October 2016 the provider was rated as Good in all five key questions. At this inspection, we found that the key questions of Safe and Well Led were now rated as Requires Improvement.

Tudor Court is a 'care home'. People in care homes receive accommodation and nursing or 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 Court is registered to provide care, nursing and accommodation to a maximum of 29 older people, some of whom may be living with dementia or memory loss. At the time of the inspection, there were 21 people living at the home.

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.

Prior to the inspection we received a number of concerns about insufficient staffing levels, pressure area care and adequate welfare checks and supervision of people living in the home. As a result of these concerns we brought our comprehensive inspection forward to look into the care provided at Tudor Court.

Risks to people were assessed and risk assessments tools were used to identify common risks such as those relating to falls, skin integrity and medicines. However, daily monitoring records did not always show that care was being delivered as it should and checks on equipment used to reduce risk, were not always accurate. People were not always protected from risks associated with their environment. Some windows did not have window restrictors and one radiator did not have a cover fitted.

Improvements were required to ensure that medicines were managed safely. Whilst medicines were stored and administering safely, random sampling of five medicines found discrepancies with the stock levels of two medicines and staff were unable to tell us how much stock they should have of another medicine. During the inspection the registered manager amended their daily medicines audit to include stock checks of boxed medicines.

The provider had systems in place to monitor the quality and safety of the home, however, these were not always robust nor effective because they had failed to identify and address the issues we found during this inspection.

People and relatives had differing opinions about the amount of staff available and if there was enough staff to meet people’s needs. One person told us, “It seems to be fine. There are always some staff around. I have no concerns.” However, another person told us, “They can be rushed off their feet." Staff also felt they were short staffed. One said, “It’s terrible we are constantly short staffed. We are not spending enough time with people. The only time you spend with residents is when you get them up in the morning.” We made a recommendation to the provider to review their staffing levels to ensure people’s needs were met.

We found that improvement was needed in relation to supporting people to maintain their social activities and interests to avoid the risk of social isolation. The provider arranged a programme of entertainers that came into the home to provide activity. There was no activity coordinator. The responsibility to generate activity fell to the staff team. However, staff told us, and we observed, that staff rarely had time to sit with people and engage them in an activity they enjoyed. One person told us, “There’s nothing you can do here, only sit in the chair.” People and staff told us that staff talked to them when providing care but did not have time to spend with them for one to one activities. We made a recomm

This unannounced inspection took place on 11 and 12 October 2016. The home was previously inspected in September 2014 and the home was meeting the regulations we looked at.

Tudor Court is a residential home in Paignton, Devon providing accommodation and care for up to 29 people. People living at the home are older people, most of who were living with dementia. On the day of our inspection, 24 people were living at the home. Accommodation consists of 28 bedrooms some had en-suite facilities.

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 and associated Regulations about how the service is run.

People told us that they were happy and felt well cared for. It was clear to see that people were comfortable living at Tudor Court and really felt they were at home. People’s care was personalised and it was evident that staff knew people they were supporting very well. We saw them interacting with kindness and compassion. People and their families described management and staff as caring, respectful and approachable. The families we spoke with had regular contact with the registered manager.

People told us they felt safe, and we found that the registered manager had a number of systems and processes in place to promote safety. Staff received training in and understood their responsibilities in relation to safeguarding adults. Staff were knowledgeable about how to recognise and report abuse. We saw risk assessments in place regarding risks associated with people's care. These explained how people's care should be delivered in a safe way and how to reduce any risks involved.

The registered manager understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Where people were deprived of their liberty applications had been appropriately made. For people who were assessed as not having capacity, records showed that their advocates or families and other health professionals were involved in making decisions in their best interests.

Staff had been recruited appropriately to ensure they were suitable to work at the home. People who lived at the home, families and staff told us there were sufficient numbers of staff on duty during the day but some concerns were raised about staffing levels at night. This was discussed with the registered manager who told us that staffing levels were determined by dependency and there were always two staff on duty at night. Rotas confirmed this. The registered manager felt that two staff would be able to meet the needs of people living at Tudor Court but would revise staffing and dependency levels within the home.

Staff knew how to meet people’s needs. Records showed they had a thorough induction and on-going training to help ensure they had the skills and knowledge they needed to provide effective care. We saw staff received regular supervision as part of their on-going development. This provided an opportunity to discuss their work, any concerns and any training opportunities they may have. We saw appropriate records were maintained to show these had taken place.

We looked at the way in which the home managed people’s medicines. Medicines were secured safely and accurate records were maintained. Staff received regular competency assessment checks to ensure the on-going safe management of medicines. Safe systems were in place to manage medicines so people received their medicines at the right times.

People and their relatives were involved in planning and agreeing how they were cared for and supported. Care was planned to meet people’s individual needs, abilities and preferences. The care plans contained information about each person, who they were and how

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People's needs were assessed and care and treatment planned and delivered in line with their individual care plan. This was recorded in the five care plans we reviewed. People's daily care was recorded by the staff providing their care on each shift. This showed that care was provided as had been detailed in the plan. The people we spoke with told us that they could make choices about their care and felt well looked after.

One relative told us "I'm much happier with my relative being here, it was such a worry them being at home. We're happy knowing they are safe and well cared for. They added "The staff are lovely and we've seen an improvement in their well being."

People who use the service told us they felt safe and were well treated by the staff. When asked if they had ever been treated badly or witnessed anyone being treated badly, one person said "All the staff are lovely. There isn't one problem at all. If there was I can approach the Manager or any of the care staff."

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards which applies to care homes. The Deprivation of Liberty Safeguards is in place to protect people's human rights. The Registered Manager said they had not needed to submit a Deprivation of Liberty Safeguards application to-date. However, the Manager was aware when an application should be made and knew where to go if an application was required.

Is the service effective?

Two relatives told us that they had visited the service before their family member had come to stay. They were shown around and were able to ask questions and given information about the care and choices that were available for their family member.

One person told us "We were lucky enough to be shown a choice of rooms. We chose the one that we thought suited them best." They added "We've seen an improvement in our family member since coming to live here, they are no longer lonely and if they are happy we are too."

People told us that they felt respected and involved in the planning of their care right from the start. One person told us "I'm very happy here, it's home from home. I was able to bring my own personal belongings for my room." They added "I had been for respite and I decided to stay. I can do as I please, my family visit, I go away with them and I couldn't be happier."

We were told care plans were reviewed monthly by care staff and reviewed annually by service users and their relatives. Examinations of people's files confirmed this was the case. This demonstrated people and their relatives had been involved in the planning and delivery of their care and had been asked to express their views. In addition we saw records were updated when people's needs changed. For example we saw people's medication was adjusted to improve their health and well being.

Is the service caring?

Decisions about care and treatment were made by the appropriate staff at the appropriate level. We saw that people's care records contained details about who had been involved in their care. We saw that healthcare professionals and clinicians had been involved in supporting people's healthcare needs when required. It was evident that the home regularly sought the support and advice of relevant professionals, such as, GP, hospitals and district nurses. This showed that staff were given information to enable them to provide care that met with people's specific needs.

People were able to choose to spend time in their rooms or in the communal areas of the home, or go out if they were able to. We observed people moving freely around the home and using the outside areas as they wished. These measures helped promote the rights and choices of the people who use the service.

Staff and the Registered Manager were knowledgeable about all the people in their care, and spoke warmly and sincerely about people using the service. We observed that all staff interactions with people were patient and respectful. There was a relaxed and friendly atmosphere in the home and we saw that people responded favourably to this. Staff were polite, respectful and friendly without exception.

Is the service responsive?

Care records also contained information on areas such as communication, behaviour, daily living, personal care, emotional needs, professional involvement and support and risk assessments. This showed that staff were given information to enable them to provide care that met the person's specific needs. Observations were made and recorded by staff if they felt people's needs were changing. This was then discussed with the individual or their representative and care plans updated to reflect a change when required.

Relatives told us that they were kept updated with their family member's progress by staff. One person said "Communication from the home is really good. They tell me if there are any changes." Another person said "Staff are constantly supportive with advice and are experienced in even difficult situations. The Manager has been a tower of strength during a difficult transition for me and my family member." This showed that people were being given information on the care and treatment being provided.

During the inspection, we looked at the quality and monitoring systems the provider had in place. People who used the service and their representatives were annually asked for their views about their care and treatment. We saw that people had completed the survey and positive comments had been made. This meant that people who used the service had an opportunity to have their say.

Following the survey the manager wrote to all service users and their next-of-kin identifying what comments had been made and what the provider intended to do to improve the service. For example some people had asked for a change to the menu and this had been done. This showed not only was the provider committed to a philosophy of continual quality improvement but was open and transparent in communications with people who used the service and their families.

Is the service well led?

All staff received one to one supervision four times a year and on-the-job supervision as and when required through supervision and observations by the manager. Any additional training needs for staff were identified and training completed if required. Supervision notes were completed and held on file. This demonstrated more structured supervision with the Manager was provided. Staff confirmed that they had the opportunity to raise any area of concern in supervision and told us that they felt well supported by the Manager and senior staff.

The Manager demonstrated a good awareness of the needs of the people that lived in the home and looked at good practice guidance in order to improve care provided. We saw that they sought professional advice when needed and this was in the best interests of the people that lived at the home.

Tudor Court was last visited by the Care Quality Commission (CQC) in April and May 2013. The last visit started at 6am as we had received information that people were being got up very early in the morning. At that visit we also found several areas that were non-compliant.

This visit also started at 6am and we looked to see if people were still being got up early and if the provider had addressed the areas of non-compliance.On this visit we found the provider had made improvements.

We found that four people were up and in the lounge when we visited. One person had declined to go to bed, one person had come downstairs because it was too warm, one person sleeping and the fourth person’s care notes stated they liked to get up around 6am.

At this visit we found there had been improvements in relation to the recording of people’s preferences and weight records. We saw that where there had been concerns over people’s weight, records showing their food and fluid intake were kept and reviewed.

We found that staff respected people’s dignity and their choices in relation to what time they got up in the morning. We did not hear people being referred to by their room number or as “singles” or “doubles” – a reference to how many staff were needed to care for them.

We saw that improvements had been made in the way care records were completed and reviewed.

We (the Care Quality Commission) carried out an unannounced visit to the service on 25 May 2012.

The home was last visited by the Commission for Social Care Inspection (the predecessor organisation of the Care Quality Commission) in May 2010.

Prior to this visit we had received several concerns about the care and treatment of people at the home. These included people being got up very early in the morning, staff using one person's underwear for another, no stimulation for people and staff not treating people with respect.

We spoke with 2 people living at the home, three staff and one relative as well as the manager and deputy manager. Because of the complexities of their illnesses, some people were unable to tell us about their experience of living at the home. Therefore both direct and indirect observation was used to assess the wellbeing and happiness of people in the home, as well as speaking with them.

We saw and heard staff treating people with respect and any personal care that was offered was given in a discreet manner. Staff told us how they respected people's privacy when helping them with personal care needs. We heard staff speaking with people in a kindly, friendly way. People that we spoke with confirmed that staff always treated them with respect. We saw staff knock on doors before entering.

People that we spoke with praised all the staff who worked at the home, especially the manager and deputy manager. One person told us "You only have to ask if you want anything". Another told us they "Loved it from the word go". A representative told us "All staff are quite nice – can't complain about the staff".

We also looked at some care records to see how people’s care was planned and delivered. We looked at the care records for three of the people who lived in the home to find out how staff at the home had assessed their health and personal care needs, and how they planned to meet those needs. Each person had a care file that contained a wide range of documents relating to their care and support needs. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. A range of risk assessments had been completed including those for pressure areas nutrition and moving and handling.

Staff told us they were made aware of any changes to people’s needs when they came on duty by staff who had worked the previous shift, and by reading people's care plans. We saw evidence that care plans were regularly reviewed and updated as people's needs changed.

There was little information available about people's lives before they lived in the home, which would have enabled staff to get to know them as individuals. This means that staff would have limited knowledge of the past lives and experiences of the people they care for.

We found that staff who administered medication had received appropriate training. We found that generally there were appropriate arrangements in place in relation to the recording of medicines.

The manager gave us a copy of the report she had produced following the 'Yearly Quality Improvement Questionnaire Audit'. The report showed the feedback received from people living at the home, their representatives and staff. Any concerns that had been raised were addressed and proposals for future improvements were outlined.

We (Care Quality Commission) visited Tudor Court as part of a planned inspection. However, following the second day of our inspection we received information of concern which related to the care and welfare of people in the home and to recruitment at the home. For this reason we carried out an out of hours third visit.

We spoke to five people, four relatives, the manager, deputy manager and seven members of staff. We looked at 10 sets of care records.

Not all the people in the home were able to speak with us so we spent two periods of time observing interactions between staff and people.

We found that people were given choice and options about their care although they were not always treated in a respectful way. Staff were knowledgeable about peoples care needs and people accessed NHS services and community healthcare. However, sometimes did not have their care needs met appropriately at the home.

Relatives were pleased with the care their family members received and people spoke highly about the staff.

There were good recruitment processes in place and effective training and induction programmes in place which were monitored well. Staff knew what to do if they suspected abuse and were aware of how to raise any concerns.

Records were securely stored and generally kept up to date however, they did not always reflect staff knowledge of care needs or the care that had been delivered.