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Archived: Tavistock Square Good

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 20 April 2015

The inspection took place on 22 and 26 October 2014. The inspection was a short notice visit, which meant the staff were informed 48 hours previously we would be visiting. We last inspected Tavistock Care Home in July 2013. At that inspection we found the home was meeting all the regulations that we inspected.

Tavistock Square provides accommodation and personal care only, for up to six adults who have a learning disability. It is located in Sunderland, close to amenities and with good transport links.

There was a registered manager at the service at the time of our inspection. We were informed during our visit how the current manager intends to transfer to another location within the company. Arrangements were already in place for the deputy manager to become the registered manager and they were waiting for approval from The Care Quality Commission (CQC). 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.

Some people we spoke with were unable to communicate verbally with us whether they felt safe living at the home. However they did display non-verbal signs when prompted by staff by smiling and gesturing with their arms Family members did confirm to us that they felt their relative was safe. Their comments included, “The staff are wonderful”; “They have worked wonders and worked very hard”, and, “I am over the moon how settled [my relative] is”.

Staff undertook risk assessments where required and people were routinely assessed against a range of potential risks, such as when using the mini bus, public transport and mobility.

Staff we spoke with had a good understanding of safeguarding and the provider’s whistle blowing procedure. They also knew how to report any concerns they had. The provider had a system in place to log and investigate any safeguarding concerns made known to them. However our records showed no statutory notifications including safeguarding concerns had been reported to the CQC. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The submission of notifications is important to meet the requirements of the law and enable us to monitor any trends or concerns We have dealt with this separately outside of the inspection process

Staff had a good understanding of how to manage people’s behaviours that challenged the service and had developed interventions and strategies to help them manage people’s behaviours that were considered challenging.

People had their needs assessed and the assessments had been used to develop person centred care plans. Care plans had been evaluated regularly each month. Where people’s needs had changed action was taken to keep them safe.

Family members of people who used the service and staff all told us they felt there were enough staff to meet people’s needs. The registered manager monitored staffing levels to ensure there was sufficient care and support staff available to meet people’s needs.

Staff were supported to carry out their caring role and received the training they needed. Training records confirmed that staff training was up to date at the time of our inspection.

Staff followed the requirements of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS). MCA assessments and ‘best interests’ decisions had been made where there were doubts about a person’s capacity to make a specific decision. The registered manager had also made DoLS applications to the local authority where required.

We observed over the lunch-time that staff made sure people were safe and had support if they needed it. We also observed that staff interaction with people was warm, kind and caring. We saw staff preparing lunch and supporting people in the communal kitchen /dining area and were provided with meals which they preferred and had requested.

People were supported to maintain their healthcare needs. Family members told us that staff provided support to their relative to attend health appointments. Another said, “They look after my relative’s needs and keep me informed if there are any concerns.”. Other family members said, “I visited the home the other evening and I was told how [my relative] had enjoyed his recent holiday with members of the staff team.”

The home’s complaints procedure was available in different formats. None of the people or family members we spoke with had made a complaint about the care they received.

There was regular consultation with people and family members via the carer’s forums and their views were used to improve the service.

The provider undertook a range of audits to check on the quality of care provided. Some gaps were noted in the medicines records and the manager and her deputy had carried out an investigation to determine the cause. Care staff responsible for medicines administration and auditing of records will be provided with feedback from their investigation. Information was analysed to look for trends and patterns and to identify learning to improve the quality of the care provided.

Inspection areas

Safe

Good

Updated 20 April 2015

Most aspects of the service were safe. Some of the medicines records contained gaps but did not affect the safe administration of medication.

Family members confirmed that their relative was safe and secure living at Tavistock Square.

There were sufficient numbers of staff to meet people’s needs and to enable them to participate in a range of activities both in and away from the home environment.

Effective

Good

Updated 20 April 2015

The service was effective. Staff told us they were supported to carry out their job role and that they received the training they needed. We saw from viewing training records that staff training was up to date. Staff followed the requirements of MCA and DoLS. When decisions were made about depriving people of their liberty they were made to ensure any interventions were the least restrictive way of achieving this.

Family members said that their relative was supported to meet their nutritional needs. The provider had systems in place to identify and support people to eat a healthy diet.

People were supported to maintain their healthcare needs. They had access to a range of health professionals when required and supported to attend scheduled health and outpatient appointments.

Caring

Good

Updated 20 April 2015

The service was caring. Family members we spoke with gave us positive comments and were happy with the care their relative was receiving.

We observed how staff supported people during the lunchtime period. Staff interaction with people was seen to caring and respectful.

One healthcare professional told us, ““How she found staff supported and encouraged people to explore a range of different activities”.

Responsive

Good

Updated 20 April 2015

Family members and staff had been involved in person-centred planning and care reviews had taken place at regular intervals.

People had their needs assessed and the assessments had been used to develop individual care plans. Care plans had been evaluated consistently each month. Where people’s needs had changed, action was taken to keep them safe.

Families were aware of how to complain. None of the family members we spoke with had made a complaint about the care they received.

Well-led

Requires improvement

Updated 20 April 2015

Most of the service was well-led. Our records showed no statutory notifications including safeguarding concerns had been reported to the CQC There was an established manager in post. Staff told us the registered manager was supportive and could be approached at any time for advice.

The home had a quality assurance programme to check on the quality of care provided. The manager communicated effectively with staff and family members to ensure they were aware of any pending changes affecting the operation of the service.