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Archived: Cherry Tree Housing Association - 12 Tavistock Avenue Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 26 November 2016

12 Tavistock Avenue is registered to provide accommodation and personal care for up 3 people who have a learning and or physical disability. At the time of our inspection One person was living at 12 Tavistock Avenue. The provider also manages another home across the road from 12 Tavistock and the staff work at both services.

The last inspection was undertaken on 22 and 28 September 2015. We found that the service was rated 'good' and was meeting the required standards.

We inspected 12 Tavistock Avenue on the 28 September and 5 October 2016 and found that the service had continued to meet the standards.

The home did not have a registered manager in post. The registered manager had left the service six weeks before the inspection commenced. There was a new manager who was in the process of registering with CQC. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

At this inspection we found there were sufficient numbers of staff deployed to provide care safely to people living in 12 Tavistock Avenue. The manager had not informed us about incidents that required reporting which is required to help keep people safe from the risk of harm. The person were supported by staff who had undergone a recruitment process to ensure they were suitable to work in a care setting. However there were inconsistencies in the recruitment of staff depending on when they were recruited. We saw that when agency staff were used the manager did not always complete the same level as robust checks as they did for permanent staff.

Risk assessments were completed and reviewed to help staff to manage risks, Although the records were not always updated to reflect the current position. The persons medicines were managed safely and there was a process in place to for the safe ordering, storage and disposal of the persons medicines.

Staff did not feel supported by the manager and felt that they were constantly being criticised about how the service operated and spoken to in a condescending way. Staff had received training but some of the refresher updates had not been provided. We saw there were arrangements in place for staff to have an induction when they commenced their employment to help support them to carry out their roles effectively.

The persons nutritional needs were met and their food and fluid intake and weight were kept under review. The person was able to choose what they ate from the menu. However the menu was under review at the time of our inspection as the new manager felt that more ‘healthier options’ should be introduced.

The persons relatives and staff told us they were supported to maintain their health and well- being and had access to a range of health professionals. We saw that the person had a purple folder which contained a summary of healthcare appointments and records of key events.

Staff spoke to people in a kind, caring and compassionate way. We observed good interaction between staff and people and relatives confirmed this to be the case.

The persons dignity was privacy was maintained. However the person did not always get choices about how they spent their time.

The person received care that was responsive to and met their needs. Staff were aware of the persons individual needs and how to meet these, however due to management changes they were not always able to accommodate the persons needs and wishes. The person was provided with some opportunities to participate in activities mainly in the community.

There was a complaints policy and procedure in place and we saw evidence of one complaint from the other service which we say had been investigated and responded to by the Manager. There were no complaints for the person who lived at 12 Tavistock Avenue.

The person received care that was monitored appropriately by staff. The persons care plans were regularly reviewed. Audits were not effectively reviewed to ensure actions were completed, and notifications were not consistently sent to CQC when required.

Inspection areas


Requires improvement

Updated 26 November 2016

The service was not always safe.

There were not always sufficient numbers of staff on duty to keep people safe.

Staff were aware of potential abuse and demonstrated they knew how to escalate any concerns. However concerns were not always reported by the provider.

The recruitment process was not consistently robust.

Risks to people’s health had been assessed and reviewed but were not always updated to reflect the current risk.

People’s medicines were managed safely.



Updated 26 November 2016

The service was consistently effective.

People received care and support from staff who had received training which supported them in their roles.

People were supported to enjoy a healthy and balanced diet.

People were supported to access a range of health care professionals.

People were asked for consent before support was provided.

People were supported by staff who were aware of MCA requirements.



Updated 26 November 2016

The service was caring.

Staff treated people in a kind and caring way.

Staff demonstrated a good understanding of people’s needs and wishes and responded accordingly.

People’s personal and private information was stored securely.

People were sometimes asked to be involved in the development and review of care plans.



Updated 26 November 2016

The service was responsive.

Staff did not always receive training updates to ensure they continued to meet people’s individual needs.

People’s care was kept under regular review to help ensure their needs were met. However records did not always reflect this.

People were supported to engage in activities to provide them with engagement. However there had been recent changes which meant these were limited.

Complaints were responded to, however the process was protracted.


Requires improvement

Updated 26 November 2016

The service was not always well led.

There had not been a registered manager at the service since June 2016 and they had recently deregistered.

A new manager had been in post for ten weeks and had started the process of applying to become registered with CQC.

The provider had limited systems in place to assess the quality of the service provided in the home however; these were not always effective in identifying areas that required improvement.