CQC report explained · a residential care home
What the CQC found at Tavey House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found up-to-date risk assessments, safe medicines practice, suitable infection control and enough staff. The home had improved from Requires Improvement and was no longer in breach of Regulation 12.
- Effective?
- Good
- Staff had training and competency checks, and worked with health professionals to meet people's needs. Some minor improvements were needed in completing nutrition and hydration charts.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff listened to people's preferences, supported independence and protected privacy.
- Responsive?
- Good
- Care plans described people's individual needs, communication preferences and choices. People were supported with activities, complaints and end-of-life wishes.
- Well-led?
- Good
- A new management team had brought stability and clearer responsibilities. Regular audits were being used to check care, records, medicines and regulatory requirements.
What inspectors found, June 2022
Tavey House rated Good; inspectors found kind, safe care and clear improvement since the last inspection.
This was an unannounced follow-up inspection on 14 April 2022. Inspectors spoke with six people, one relative, staff and visiting health professionals. They also checked care records, staff files and management records.
People were described as happy and well cared for. Staff were kind, respectful and supported people's independence, activities, health needs and choices. Inspectors found safe medicines management, suitable risk assessments, good infection control and enough staff.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The previous overall rating was Requires Improvement in July 2021. The provider had made enough progress and was no longer in breach of the regulations mentioned in the previous report.
Kind and respectful staff
People and relatives described staff as caring, attentive and respectful. Staff spent time with people and provided emotional support when needed.
“The staff are fantastic. [Person] has taken to every single one of them and they're like family.” from the report
Improved safety
Risk assessments, medicines systems, emergency plans and infection control had improved since the previous inspection. Staff knew how to respond to risks and accidents.
“Risk assessments were up to date and comprehensive. They included the information staff needed to protect people from harm.” from the report
Personalised care
Care plans recorded people's likes, dislikes, routines, communication needs and preferences. People were supported to make choices and remain as independent as possible.
“Care plans set out people's individual needs to give staff a good understanding of what these were and how to meet them in line with people's preference.” from the report
Good partnership working
Health professionals said staff knew people well, shared information and contacted health services when needed.
“They told us staff knew when to call them in, kept good records, shared information where appropriate, and followed instructions when meeting people's heath care needs.” from the report
Stronger management oversight
The new management team had assigned responsibilities and used regular audits to monitor care and safety. People, relatives and staff said managers listened and acted on suggestions.
“The service had a new management team who provided stability and leadership at the service.” from the report
Nutrition records
minorInspectors found that some weight and nutritional screening charts needed minor improvements in how they were completed. The provider said it was addressing this.
“Some minor improvements were needed to the way these charts were completed and the provider was addressing this.” from the report
Further dementia-friendly changes
minorThe home was still considering changes to make the premises more dementia friendly. One person also wanted more colour and pictures in the lounge.
“The provider was looking into making the premises more 'dementia friendly' to further meet the needs of people living with dementia.” from the report
Complaint procedure update
minorA complaints book and procedure were available, but the provider was updating the procedure to make it simpler and easier to use.
“The provider said the complaint procedure was being updated to make it simpler and more user-friendly.” from the report
- 01Have the minor problems with completing weight and nutritional screening charts now been fully corrected?
- 02What changes have been made to make the home more dementia friendly, including the planned use of colour, pictures and items of interest?
- 03Who is the registered manager now, and how has the management arrangement changed since the inspection?
- 04Has the complaints procedure been updated, and how can families raise and track a concern?
- 05How are people's end-of-life wishes and ReSPECT forms kept up to date?
This was an unannounced follow-up inspection covering all five key questions, with infection prevention and control also checked under Safe. This explanation was written from the published report of 1 June 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2021
Rated Requires Improvement; inspectors found kind staff but serious gaps in risk assessments, medicines, infection control, training and management oversight.
This was an unannounced inspection on 18 May 2021. Inspectors spoke with people, relatives, staff and managers. They checked care records, medicines records, audits, policies and infection control documents.
The home had enough staff and people were generally supported by a kind and caring team. The premises were clean, well-decorated and furnished. However, records and systems were not reliable enough to show that people's needs would always be met safely.
Inspectors found problems with risk assessments, medicines, infection control, staff training, consent, care plans and management checks. The overall rating and all five question ratings were Requires Improvement. All five ratings had fallen from Good at the previous inspection.
Kind and respectful staff
Staff were described as kind, caring and respectful. Inspectors saw staff comfort someone who was anxious, helping them become more relaxed.
“Staff were caring and respectful. They had time to sit and socialise with people.” from the report
Enough consistent staff
There were enough staff on duty during the inspection, and rotas showed consistent staffing. Most staff were permanent and knew people well.
“On the day we inspected there were enough staff on duty to meet people's needs.” from the report
Clean and improved premises
The premises had been upgraded since the previous inspection and were clean, well-decorated and furnished.
“The premises had been upgraded since we last inspected and were clean, and well-decorated and furnished.” from the report
Activities and family contact
People took part in activities including gardening, board games, music and singing. During the pandemic, staff kept relatives in contact and arranged video calls.
“One the day of our inspection activities were provided, and we saw people enjoying gardening, board games, music, and singing.” from the report
Incomplete risk information
seriousSome people did not have risk assessments or care guidance for choking, distress during personal care or other known risks. Emergency evacuation plans did not explain how some people could leave safely if the lift could not be used.
“Risk assessments did not always contain the information staff needed to keep people safe.” from the report
Unsafe medicines systems
seriousInspectors found unsafe insulin storage, missing tablets, incomplete records and unclear instructions for patches, nutritional drinks and blood tests.
“The provider failed to ensure medicines were properly and safely managed.” from the report
Infection control gaps
seriousCOVID-19 guidance was not consistently followed. Most staff had not completed infection control training, and policies were out of date.
“The provider failed to properly assess the risk of infections at the service and take action as necessary to reduce that risk.” from the report
Training and supervision gaps
needs fixingOnly three of nine permanent staff had completed all essential training. Some staff had gone years without planned supervision, competency checks or appraisals.
“The training matrix showed significant gaps. Only the registered manager and another staff member had completed all their essential training.” from the report
Weak management checks
seriousAudits did not identify problems with medicines, care plans, risk assessments, staff training or falls. This meant opportunities to improve care were missed.
“Systems and processes were either not in place or robust enough to demonstrate the service was effectively managed and shortfalls identified and addressed.” from the report
- 01What has been done to make sure every person has a current risk assessment, including for choking, distress during personal care and emergency evacuation?
- 02How are medicines now stored, checked and recorded, including insulin, patches, missing tablets and as-required medicines?
- 03What infection control training have all staff completed, and how are COVID-19 guidance and infection control policies kept up to date?
- 04Which staff still need essential training, supervision or competency checks, and how will you monitor completion?
- 05How do you check that care plans include people's preferences, communication needs, consent and end of life wishes?
This was an unannounced inspection that considered all five CQC questions and included infection prevention and control checks; the report does not state a named inspection type. This explanation was written from the published report of 30 July 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Tavey House
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- June 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- December 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 14 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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At least 100 live-in carers within about an hour of Leicestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 82 can care for a couple. 12 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
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