Tudor Manor

People and those important to them were supported to understand safeguarding and how to raise concerns when they did not feel safe. Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to the manager. When concerns had been raised, the manager did not always report these promptly to the relevant stakeholders, there was no evidence to show lessons were being learnt following each incident. This meant that action was not always taken to prevent people from further risk. Safety risks to people were not always managed well. The manager completed risk assessments. However, not all high risks were individually assessed to meet people’s choices and preferences. Where care plans and risks assessments were created, the manager made sure people, and those important to them, were involved in making decisions about how they wished to be supported to stay safe. There were not always enough staff to support people with their needs. The deployment of staff had not been assessed to ensure staff were always present around the home. Staff received relevant training to meet the range of people’s needs at the service. Staff received support through supervision and appraisal to support their continuous learning and improve their working practice.

Peoples needs and rights were supported. Peoples care and treatment was effective due to their health, care, well-being, and communication needs being assessed with them. Peoples care plans were kept up to date with any assessments completed in a timely manner. Staff were aware of people’s preferences and respected these in a person-centred way. People were aware of their rights around care and treatment. Staff have good knowledge of the mental capacity act, including capacity and consent. Staff were aware of how to support someone with fluctuating capacity.

People were supported to live in a safe, inclusive environment in which they were treated fairly and free from the fear of being discriminated against. People were supported to understand their equality and human rights and how staff and managers would respect these. Managers made sure staff were given appropriate training and supported to treat people equally and fairly and reduce the risk of them being excluded from receiving care and support they were entitled to. Managers used people’s feedback to improve care to reduce any barriers people might experience due to their protected characteristics.

There were governance systems in place, however, these were not effective in identifying the concerns we identified/saw during this assessment. Staff understood their role and responsibilities. Managers accounted for the actions, behaviours, and performance of staff. Data or notifications were not always consistently submitted to external organisations as required. Leaders worked in partnership with local authorities and quality teams to improve the quality of care and service provided.