We carried out a review of the data available to us about Tavey House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Tavey House, you can give feedback on this service.
Tavey House is a residential care home registered to provide accommodation and personal care for up to 12 older people, some of whom are living with dementia. At the time of the inspection there were 10 people using the service.
People’s experience of using this service and what we found
People were happy living at Tavey House and praised the premises, the staff, and the care provided. A person said, “It’s a beautiful place, I enjoy living here.” A relative told us, “[Person] absolutely loves it here and the family’s minds are at rest as we know they are well looked after. I would certainly recommend this home.”
The staff were caring and looked after people with kindness and respect. They encouraged people to be independent, where possible, and to enjoy individual and group activities. A relative said, “The staff are fantastic. [Person] has taken to every single one of them and they’re like family.”
Health care professionals said staff worked well with them and were ‘proactive’ in referring people to health care services when needed. They made positive comments about how well the staff knew the people they supported, and the quality of record keeping and information sharing.
The service’s new management team ensured people received good quality care and support. They carried out regular audits to check the service was running well, record-keeping was in good order, and people were safe.
People, relatives and staff were encouraged to share their views on the service. They said managers listened to them and made changes where necessary. People and relatives said all managers and staff were approachable and helpful and wanted the best for the people living at Tavey House.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was Requires Improvement (report published 30 July 2021). The overall rating for the service has improved to Good. This is based on the findings at this inspection.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection. At this inspection, improvement had been made and the provider was no longer in breach of regulations.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Tavey House provides accommodation and personal care for up to 12 adults with needs relating to dementia, physical disabilities, and mental health. The service is divided into four separate units.
On the day of our inspection visit there were 11 people using the service.
People’s experience of using this service and what we found
People were not always protected from the risk of avoidable harm due to poor quality risk assessments. Although staff knew people well, they did not always have the information they needed to keep people safe.
Improvements were needed to medicines safety, safeguarding policies and procedures, and infection prevention and control. Lessons were not always learnt when things went wrong.
Staff had not always had the essential training and supervision they needed to work in care.
The provider and registered manager did not have proper oversight of the service. Some audits were ineffective, or non-existent, and opportunities to improve care had been missed.
Improvements were needed to the provider’s assessment procedure, care plans and records. We have made recommendations to the provider about these.
We found no evidence of people being harmed or left without care, however, due to poor quality record keeping and a lack of oversight, we were not assured that people’s needs would always be met and they would always be safe at the service.
The service was well-staffed with a kind and caring team. Staff were knowledgeable about people’s care needs. The premises had been upgraded since we last inspected and were clean, and well-decorated and furnished.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Why we inspected
The inspection was prompted in part due to concerns received about people’s care. A decision was made for us to inspect and examine those risks.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to safe care and treatment, consent and governance at this inspection. Please see the action we have told the provider to take at the end of this report.
You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Tavey House on our website at www.cqc.org.uk
This inspection took place on the 12 and 14 September 2017. The first day of our visit was unannounced. This meant the staff and the provider did not know that we would be visiting. We returned announced to complete our inspection on the second day. At our last inspection in November 2016, the service was rated requires improvement. We asked the provider to take action to make improvements with regard to the numbers of staff on duty at the service. At this inspection we checked to see if the provider had made the necessary improvements. We found that improvements had been made.
The service had two registered managers. 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 told us they felt safe living at Tavey House. The staff team had received training in the safeguarding of adults and knew their responsibilities for keeping people safe from avoidable harm. This included reporting their concerns to the registered manager and the management team.
Risks associated with people’s care and support had been appropriately identified, assessed and managed.
People had plans of care that reflected their care and support needs. These had been regularly reviewed and provided the staff team with the information they needed in order to support people in a way they preferred.
Appropriate checks had been carried out when new members of staff had started working at the service. This was to make sure they were suitable and safe to work there. An induction into the service had been provided and training relevant to their role had been completed.
People received their medicines as prescribed. Appropriate records were being kept and systems were in place to regularly audit the medicines held.
People felt there were enough members of staff on duty each day because their care and support needs were being met. Their relatives and friends agreed. The registered manager told us they monitored the staffing numbers to make sure there were enough staff on duty to meet people’s needs.
People's food and drink requirements had been assessed and a balanced diet was being provided. Records kept for people assessed as being at risk of not getting the food and drinks they needed to keep them well were up to date.
People were assisted to access relevant healthcare services such as doctors, district nurses and podiatrists and they were supported to maintain good health.
Staff members were aware of their responsibilities under the Mental Capacity Act 2005 though not all had received training on this topic. People had been involved in making day to day decisions about their care and support and the staff team understood their responsibilities with regard to gaining people's consent.
The staff team treated people with respect and promoted their privacy and dignity. Throughout our visit we observed the staff team treating people in a kind and considerate manner.
Relatives and friends were encouraged to visit and they told us they were made welcome at all times by the staff team.
Staff members felt supported by the management team and told us there was always someone available to talk with should they need guidance or support.
Staff meetings and meetings for the people using the service and their relatives and friends had been held. These provided people with the opportunity to be involved in how the service was run.
People using the service and their relatives knew what to do if they had a concern of any kind and were confident that any concern raised would be dealt with appropriately.
Regular checks had been carried out on the environment and on the equipment used to maintain people's safety. Systems were in place to regularly check the quality and safety of the service being provided and a business continuity plan was in place.
The registered managers' understood their legal responsibility for notifying the Care Quality Commission of deaths, incidents and injuries that occurred or affected people who used the service.
Tavey House provides accommodation for up to 12 people who require personal care and support. There were 12 people using the service at the time of our inspection including people living with dementia.
The service 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. The care manager was in the process of applying to share the registered manager’s post with the current registered manager.
There were not always enough suitably deployed members of staff on duty to meet the needs of the people using the service. This was because there were times when there were only two care workers on shift to support 12 people, three of whom needed two care workers to support them with their mobility.
Relatives we spoke with told us that their relatives were safe living at Tavey House and they were properly supported by the staff team. Staff members had received training on the safeguarding of adults and they knew what to do if they were concerned for someone.
Checks had been made when new staff members had been employed, though the reasons for leaving their previous employment had not always been explored.
People’s needs had been assessed and the risks associated with their care and support had been assessed and managed.
Care plans had been developed for each person using the service and the staff team knew the needs of the people they were supporting well.
People were supported by a staff team with the right skills and knowledge. Staff members were supported through training and supervision and were aware of their responsibilities under the Mental Capacity Act 2005.
People had been involved in making day to day decisions about their care and support and the staff team understood their responsibilities with regard to gaining people’s consent.
People received their medicines as prescribed though the recording of ‘as and when required’ medicines needed some clarification.
People’s nutritional and dietary requirements had been assessed and a balanced diet was provided, with a choice of meal at each mealtime. Monitoring records used to monitor people’s food and fluid intake were not always completed accurately. This was addressed during our visit with the care manager implementing a new procedure for recording how much people had eaten that was more reliable than the one we had seen.
Staff meetings and meetings for the people using the service and their relatives had been held and surveys had been completed. This provided people with the opportunity to be involved in how the service was run.
The care workers we spoke with felt supported by the care manager and they felt able to speak with them if they wanted to raise any issues. They respected people’s privacy though needed to be reminded of supporting people in a dignified way. This was done during our visit to the service.
People using the service had access to the required healthcare services and received ongoing healthcare support.
A complaints process was in place and people who were able to verbally communicate with us told us they knew who to talk to if they had a worry of any kind. Relatives knew who to talk to if they had a concern and were confident that anything raised would be dealt with appropriately.
Monitoring systems were in place to monitor the quality and safety of the service being provided though these were not always effective in identifying shortfalls, in particular, staff deployment.
We found the service was in breach of one of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of the report.
This inspection took place on the 14 October 2015 and was unannounced.
Tavey House provides accommodation for up to 12 people who require personal care. There were 12 people using the service at the time of our inspection including people living with dementia.
The service 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.
Not everyone we spoke with felt there were always enough staff on duty to meet the needs of the people using the service. Our observations also questioned whether enough staff members were on duty to meet people’s care and support needs. The management team acknowledged this and steps were being taken to increase the staffing levels.
People using the service were not always protected by the provider’s recruitment processes. This was because people had started working at the service before the required checks had been received.
People who were able to talk to us told us they felt safe living at Tavey House and care workers were aware of their responsibilities for keeping people safe.
People’s needs had been assessed prior to them moving into the service and plans of care had been developed from this. The risks associated with people’s care and support had also been assessed. Assessing risks enabled the management team to minimise risks associated with people’s care and support on an on-going basis.
People received their medicines as prescribed and in a safe way but not all of the necessary documentation was in place.
People had been involved in making day to day decisions about their care and support and assessments had been carried out when necessary, to assess people’s ability to make decisions for themselves. Although the care manager was knowledgeable about the Mental Capacity Act 2005, not all of the staff members we spoke with had received training on this subject.
People’s nutritional and dietary requirements had been assessed and a balanced diet was provided however, choices were not always offered at every meal time.
Throughout our visit we saw the staff team treating people in a caring and considerate manner. People we spoke with told us that the staff team were respectful toward them.
Care workers felt supported by the management team. They had been provided with an induction into the service, however not all of the training relevant to their role had been made available to them.
People using the service and their relatives had been encouraged to share their thoughts of the service provided. Daily dialogue with the staff team and management was encouraged and regular meetings had been held.
There were systems in place to monitor the service being provided, though these had not always been effective in identifying shortfalls, particularly within people’s care records.
The detailed evidence supporting our summary can be read in our full report.
Is the service safe?
Because of communication difficulties that people had, we only spoke with three people who lived in the service. People told us they felt safe. Five relatives we spoke with also said they thought their relatives were safe in the service.
The service was clean and odour free. We not see any obstacles which would get in people's way and trip them.
However, there were times when we saw if two care staff were assisting a person, no other staff had been present to check that people in the lounge were safe. This meant that people had not been fully protected from the risk of accidents or the possible behaviour of other people living in the service.
The provider has told us what they are going to do to meet the requirements of the law in relation to providing a safe environment.
Is the service effective?
Specialist dietary needs had been included within care plans and care staff told us that they had read the plans. However, we saw that a plans of care had not always been followed in providing relevant care to ensure person's needs had been met. We have asked provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring the health needs of people is fully protected.
Relatives we spoke with confirmed that they were able to see people in private and that visiting times were flexible.
Is the service caring?
People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people. One person told us; 'staff are good. They help us all the time'.
A relative told us; 'staff are helpful all the time. I think my mum receives a fantastic service.'
We spoke with two members of staff, the registered manager and general manager. We looked at some of the records held in the service, including the care files for four people who used the service. We also used observation to understand people's experience, as some people had communication needs and were unable to tell us their views and experiences.
We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask. This is a summary of what we found.
Is the service safe?
People told us they felt safe and well cared for. Comments included, 'I feel safe and well cared for.' And, 'I love living here, the other ladies I live with are nice, staff look after us very well, you can ask for anything.'
Relative and friends told us they were happy with the service provided. Comments included, 'It's a marvellous service, I have no concerns, people are well looked after.'
The provider completed a pre-assessment before people moved in to the service to make sure people's assessed needs could be met. Review systems were in place to ensure care plans and risk assessments were up to date and kept people safe.
Equipment was regularly serviced to ensure it was in safe working order.
We found some concerns with the staffing levels during a part of the day and night. The provider had assessed that some people had needs that required two members of staff to support them. There was not enough staff available to meet people's needs over a 24 hour period.
Is the service effective?
People told us they felt cared for appropriately. We saw examples where people had been unwell and the provider arranged for health care professionals to visit, such as the doctor or district nurse.
We saw the provider supported people to attend outpatient appointments or arranged for health professionals to visit people within the home such as an optician.
The provider had systems in place that demonstrated they co-operated with other health and social care professionals. This meant people received a person centred and coordinated approach to their health, safety and welfare needs.
We saw the provider used assisted technology as an additional method to support some people who were at risk of falls.
Is the service responsive?
We saw the provider had a complaints policy that was accessible for people and visitors. This enabled people to know their rights and how to make a complaint if they wished to do so.
The provider had developed positive contacts and links with people's primary and secondary medical services. People could be assured their health care needs were monitored and responded to appropriately.
Is the service caring?
People who used the service, relatives and friends spoke highly of the service. Comments included, 'I visited many homes before deciding on this one, the others didn't live up to my expectation.' And, 'I like the ethos of the home. It's very caring, communication is good and I feel involved in discussions and decisions.'
We observed staff to support people in a caring and sensitive manner. People looked relaxed and comfortable in the presence of staff.
Is the service well-led?
The provider had quality assurance systems in place. People who used the service and visitors had opportunities to share their views and wishes.
Care plans and risk assessments were reviewed at regular times to monitor people's needs.
We observed staff talking with and assisting people throughout the day, this was done with the peoples' privacy and dignity in mind and showed the staffs' awareness of peoples individual support needs. Care plans are descriptive and easy to follow, and when we asked staff they were aware of people's needs. We looked at how medicines are administered and found that these are well managed.
We saw the programme of refurbishment had commenced though we did not actually see the plan. One area that had been upgraded was the laundry, though we noted that this had to be completed to ensure people's safety.
We observed staff talking with and assisting people throughout the day, this was done with the peoples' privacy and dignity in mind and showed the staffs' awareness of peoples individual support needs.
We looked at the quality assurance used to monitor and improve the safety for people. We looked at the staff training courses and the paperwork used to test the staffs' knowledge. We also looked at the range of tests undertaken by staff and external contractors, to again ensure people are safe. We looked at the medication system and noted three missing signatures, but confirmed the medication had been administered. We also noted these errors were confined to medications that were prescribed to be taken prior to meals, and have asked the manager to increase the oversight of the medication system to pick up these minor issues.
We looked around the home and noted the ongoing refurbishment programme. Visiting relatives told us that this was undertaken with the people using the service comfort in mind as they had seen a builder leaving doors open and trying to access the home in an unauthorised way, only to be reminded by staff of the appropriate, safe pre agreed route.