Care Quality Commission
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Staffordshire care home is rated inadequate and placed in special measures by CQC

The Care Quality Commission (CQC) has rated Marquis Court (Tudor House) Care Home in Cannock, Staffordshire, inadequate and placed it in special measures following an inspection in November and December.

This inspection was carried out to find out if the provider had made the required improvements to issues which were highlighted at the last inspection.

At this recent inspection, we found a repeated breach of regulations in relation to governance and oversight. There were also further breaches regarding people's safe care and treatment, person centred care, nutrition and hydration care and staffing issues. This service has been rated requires improvement for the last nine consecutive inspections.

The home’s overall rating has now dropped from requires improvement to inadequate. It has also dropped from requires improvement to inadequate for being responsive and well-led. Safe and effective has declined from good to inadequate. Caring was not looked at during this inspection, therefore remains rated good.

The service is now in special measures which means it will be kept under even closer review, by CQC and re-inspected to check sufficient improvements have been made.

Marquis Court (Tudor House) Care Home is a nursing home providing accommodation and nursing and personal care for up to 52 older adults. At the time of this inspection 26 people were living at the home, some of whom were living with dementia.

Amanda Lyndon, CQC head of hospital inspection for adult social care, said: 

“When we inspected Marquis Court (Tudor House) Care Home, we found widespread and significant shortfalls within leadership which was impacting on people’s care.

“This service has been rated as requires improvement at its last nine inspections, and despite us telling leaders very clearly, where they needed to improve, there has been little to no progress against previous breaches in regulation, and now we’ve seen a decline in the quality of care being provided with further breaches.

“Leaders weren’t managing the service well, and staff didn’t have a clear consistent understanding about quality performance requirements and risks. For example, the management team had completed an action plan to address concerns they had found. However, this had failed to identify and take immediate action to deal with the concerns we found during our inspection. This placed people at a continued risk of harm.

“There wasn’t enough staff to ensure people's basic care needs were being met in a timely way. We were told of times where people didn’t have support with personal care until midday or later which is totally unacceptable. Also, people weren’t able to have a shower when they wished to, with one staff member telling us that they were only able to support people to shower once a week because they didn’t have enough time to do more.

“Where people had experienced weight loss, staff had referred them to external agencies for review and further support. However, staff weren’t consistently providing people with the support external agencies recommended. For example, one person had a pureed diet due to risk of choking and required staff to observe them at mealtimes however they did not receive this, which placed them at an increased risk of choking.

“We will continue to monitor the service closely to ensure people are safe and improvements have been made and embedded. If we are not assured people are receiving safe care, we will not hesitate to take further action.”

Inspectors found:

  • People had to wait for their care, as there were not enough staff to support them in a timely way. People did not receive the support they required around mealtimes, pressure care and wound care. This had resulted in people losing weight and the condition of their skin deteriorating. People experiencing periods of anxiety and distress did not have care plans to enable staff to meet these needs in a consistently safe and effective way
  • People's dignity was not promoted. Staff used disrespectful language to describe people's needs. People had limited access to activities and personalised care in line with their needs and preferences. People and relatives were not happy with social activities available to occupy their time. People were not safeguarded from potential harm as they were not receiving the care and support they required
  • People were not supported in a safe environment as doors were left open to rooms containing harmful substances. People did not have end of life care plans in place which comprehensively explored their needs and wishes at the end of their lives
  • Although people and their relatives knew how to complain, complaints were not always acted upon. Governance systems were ineffective as they had not identified the concerns found at this inspection
  • Leadership at the home was inadequate and improvements had not been identified or embedded to ensure people experienced good quality care and support.
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