We carried out a review of the data available to us about Avon Lee Lodge 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 Avon Lee Lodge, you can give feedback on this service.
We found the following examples of good practice:
People, staff and visitors to Avon Lee Lodge were protected from risks of infection as policies and staff practices reflected best practice guidance. Visiting was by appointment only. Staff trained in infection, prevention and control (IPC), met visitors at the entrance. This ensured adherence to the guidance, including checking temperatures, a health questionnaire, hand cleansing and wearing personal protective equipment (PPE).
The premises and equipment were visibly clean. The cleaning schedule and housekeeping staffing hours had been reviewed and reflected the additional cleaning required to help keep people safe.
Changes to the environment included creating safe indoor visiting areas which included screening between people and their visitors and utilising an external door avoiding non-essential visitor footfall in the building.
People were kept up to date with government guidance aimed at keeping them safe, involved in decisions, and their consent obtained. This included consent to testing and receiving a vaccine.
Risks to people’s mental well-being were understood and actions to reduce risk of social isolation had included video calls to family and friends and increased social visits to people’s rooms when self-isolating. A video tour of the home had been produced to help people new to the home familiarise themselves with their surroundings when initially self-isolating.
PPE was used correctly, in good supply and available throughout the home. People and the staff team were able to participate in regular testing in line with government guidance. Staff were up to date with IPC training including how to put on and take off their PPE safely. A monthly support call was being provided by a designated IPC lead from the local health authority.
We have also signposted the provider to resources to develop their approach.
Further information is in the detailed findings below.
At the last inspection, the service was rated ‘Good’. At this inspection we found the evidence continued to support the rating of good and there was not evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.
People were protected from avoidable harm as staff understood how to recognise signs of abuse and the actions needed if abuse was suspected. There were enough staff to provide safe care and recruitment checks had ensured they were suitable to work with vulnerable adults. People had their risks assessed and regularly reviewed. When people were at risk of falling, skin damage, infection or malnutrition staff understood the actions needed to minimise the risk. The service was responsive when things went wrong and reviewed practices in a timely manner.
People had their needs and choices assessed prior to admission to Avon Lee Lodge and this information had been used to create person centred care plans that recognised people’s diversity and lifestyle choices. Access to healthcare was available when needed and working relationships with health professionals enabled effective care outcomes for people. The principles of the Mental Capacity Act were followed which ensured people had their rights protected.
The environment, design and use of technology effectively met the needs of people and enabled them to live more independent lives. People felt involved in decisions about their day to day lives and had their dignity and privacy respected. A complaints process was in place which people and their families felt they could use and would be listened too.
The service had an open and positive culture and had systems in place to engage and involve people, their families and staff in service delivery. Leadership was visible and promoted teamwork. Staff had a clear understanding of their roles and responsibilities and described the home as organised and well led. Audits and quality assurance processes were effective in driving service improvements. The service understood their legal responsibilities for reporting and sharing information with other services.
Further information is in the detailed findings below
An unannounced inspection took place on the 9 December 2015. The inspection continued on the 11 December 2015 and was announced. The inspection was a planned comprehensive inspection carried out by one inspector.
The service is registered to provide accommodation and personal care for up to 24 people. At the time of our inspection there were 20 people living at the service.
The service provides accommodation over three floors. There are 23 bedrooms, six of which are suitable for two people. At the time of our inspection all the rooms were being used as single occupancy. Each room has an en-suite toilet and wash basin. There was a call bell system fitted in each room. There are two bathrooms with specialist bathing facilities on the first floor. We found that one bath had been out of action for several weeks due to a safety issue. We were told by the Director that they were in regular communication with the manufacturer to get the issue resolved. The first and second floors can be accessed by either a lift or staircase. On the ground floor there is a large dining room which also has cinema equipment installed for film shows. There is a conservatory that people used to spend time together which looks onto secure gardens that have level access from the building. There is a kitchen that produces all the meals for the service and an on-site laundry service.
The service has 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.
We found that the service was safe. People living at the service and their families told us that they felt safe. Staff had received safeguarding training and had a good knowledge of how to identify potential abuse and who to contact if they had concerns. Records showed us that the service report safeguarding concerns promptly and appropriately.
People’s risks were assessed prior to admission and then reviewed regularly. They included malnutrition, skin integrity and moving and handling. When a risk had been identified a care plan had been put in place. This explained what actions needed to be taken to minimise risk and keep the person safe. Other general risk assessments included slips and trips, infection control, accessing the staircase and staff related risks.
People did not have personal evacuation plans in place. These are needed to ensure each person’s individual risks are understood in the event of an emergency. Staff had completed fire safety and the correct use of fire extinguishers training. Fire equipment was regularly tested. The service did not have an emergency contingency plan in place. An emergency contingency plan needs to contain information on how the service would keep people safe in the event of a major incident which affected the running of the service. We raised this with the registered manager who agreed to complete personal fire evacuation plans and an emergency contingency plan.
Staff were recruited safely. Files contained evidence of criminal record checks, references and eligibility to work in the UK. Processes were in place to manage any unsafe practice and we found evidence in supervision records of them being used appropriately. People told us they felt there were enough staff to support them safely. We activated a call bell in a room and after 15 minutes no staff had come to answer the call. We discussed this with the Director who told us that staff had responded but the call had shown in the wrong location. The issue was immediately investigated and actions put in place to rectify the problem. Call bell records showed us that staff responded usually within one to three minutes.
Medicines were managed safely. People’s Medicine Administration Records (MAR) were maintained and medicine audits regularly carried out by the manager. Controlled medicines require additional security and recording processes. The records were well maintained and accurate. However creams were stored in people’s rooms and there was no consistent recording of their application. The deputy manager was in the process of introducing a new recording system. Records would include a body map showing where the cream needed to be applied and an administration recording sheet where staff signed to confirm application. Staff were aware of the process for reporting medicine errors.
We found the service was not always effective. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.
People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS).
We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met.
We found that the service were not working within the principles of the MCA. We were told that some people were living with a dementia. People’s files did not contain any evidence that their capacity had been assessed when care plans had initially been developed or reviewed. People had not had their mental capacity assessed to determine whether they were able to consent to restrictions on their liberty or if a DoLs application was required in line with the MCA legislation. One person had a DoLs in place which their social worker had completed on admission to the service. Staff were aware of the conditions of the authorisation and when it needed to be reviewed. We discussed our findings with the registered manager who had completed MCA training but recognised her knowledge was out of date. During our inspection training was booked for January for herself and the deputy on the implementation of the MCA and DoLs legislation. We observed staff seeking verbal consent and giving people time to ask questions and consider the information before giving their consent.
Staff received an induction that enabled them to effectively carry out their roles. This included a four day introduction to the care certificate. The Care Certificate is a national induction for people working in health and social care who have not already had relevant training. Records were kept of the training staff had undertaken and dates for when it needed to be reviewed. Staff received regular supervision which included checking competencies after training.
People told us that the food was good. The kitchen had a good knowledge of the dietary requirements of people. We saw that one person had been losing weight. Risk assessments were in place and reviewed regularly. The kitchen and care workers had a good understanding of what they needed to do to support this person. The service had responded quickly in getting support from a GP and dietician. Staff supported people with their meals in a relaxed and discreet manner. Specialist equipment was used to support people to maintain their independence at mealtimes. People were regularly offered drinks throughout the day.
People had good access to healthcare. This included opticians, audiologists, chiropodists and specialist health professionals at the hospital, GP’s and district nurses.
We found that the service was caring. We spoke with people, their families and other professionals who told us that staff were caring, kind and compassionate. People were supported in a professional and unhurried way. Staff had a good understanding of people’s care needs. They knew people’s likes and dislikes and how they liked to receive their care and support. People were regularly checked upon when in their rooms. People felt involved in decisions about their care. Staff involved people in choices about how they wanted to spend their time. They were supported and encouraged to maintain their independence. People felt that their dignity and privacy was respected. Rooms had been personalised with photographs and personal belongings. People felt their rooms were their own personal space. Relative’s told us they were kept informed of any changes or concerns.
People had not been provided with information about advocacy services. We spoke with the registered manager who told us that they would source a local advocacy service and share the information with people including a poster with contact details.
We found that the service was responsive. People had their care needs assessed and reviewed regularly. Care files and reviews included involvement of staff, the person and their family. Changes in people’s care needs were identified quickly and when necessary other professionals were involved in supporting. Staff had a good understanding of people’s care plans and felt well informed about people.
People were supported to follow their interests which included bird watching and listening to music. Activities and entertainment were organised for most days in December. This included children from a local school visiting, musical entertainers, quizzes and games. People were supported to maintain contact with friends and family. The service had worked with health professionals to support a person with complex health issues regain the ability to sit in a chair so that they were able to engage more with activities.
People were aware of the complaints process and they felt staff listened. Complaints were recorded, investigated and responded to with findings and actions. Responses included information about the Local Government Ombudsman.
We found that the service was well led. The registered manager was available throughout our inspection and had a good knowledge of the people living at the service. Interaction between staff and the manager was relaxed and professional. We were made aware prior to our inspection that there had recently been a change in management arrangements. We asked people, their families and staff whether this had impacted on the care people received. They were aware that changes had taken place but had not felt any negative impact.
Notifications were not always sent to CQC in a timely manner. A notification is the action that a provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them. This had been identified by the registered manager who had accessed information on the CQC website which provides guidance for providers on their responsibilities.
Staff we spoke with felt supported and able to share their views or concerns with management.
The service bi-annually sends a quality assurance survey form to people, their families, staff and other professionals to gather their views on the service. Results from a survey in April 2015 had been analysed by the management team. We looked at the results and the feedback had been positive. The survey results had not been shared with people, their families or staff. We discussed this with the manager who told us they would introduce this into their quality assurance process.
The service carried out regular audits which included medicines, accidents and incidents, health and safety, fire, cleaning, staff training, care files, night checks, infection control , call bell and equipment maintenance checks. Audit records showed areas where issues had been identified and actions taken.
Is the service safe?
Care was planned and delivered in a way that was intended to ensure people's safety and welfare. Risk assessments were regularly reviewed and amended as required according to changes identified. Effective assessment of care needs and management of risks showed how the home supported people's welfare and took appropriate steps to ensure their safety.
People were protected from risk of infection by using facilities that were maintained to an acceptable standard of cleanliness and hygiene.
The premises and grounds were clean, tidy and in a good state of repair. The provider's maintenance systems ensured people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.
Appropriate security arrangements were in place at the home to protect people who used the service. Those arrangements helped keep people secure but also allowed them to come and go as freely as possible.
Is the service effective?
Care needs assessments, which covered areas such as eating and drinking, mobility and personal care, were clear and concise. Plans were regularly reviewed and were updated as necessary following changes to people's care needs. This helped ensure people's needs continued to be met if and when they changed.
Staff received regular and ongoing training related to meeting the needs of people at the service. This included care of medicines, Mental Capacity Act (2005), moving and handling and infection control. People at the service benefited from the provider taking steps to ensure staff were sufficiently qualified and skilled to provide effective care and support.
Is the service caring?
People were supported by kind and attentive staff. Care was observed to be respectful and responsive to individuals' needs. We saw that staff were patient and gave encouragement when supporting people. People told us they were happy and liked living at the home. One person told us, 'The girls [staff] are so nice, the girls are lovely ' I would recommend it [the home] to anybody.' Another person said, 'You can't fault it really.' One relative told us their parent, who lived at the home, 'seems very comfortable, very happy.' Another relative told us, 'Staff go the extra mile ' the ABCD, Above and Beyond the Call of Duty.'
Is the service responsive?
The provider staffed the home according to the care needs of people living there. In response to concerns identified through a recent local authority led investigation and their own internal quality assurance processes, the provider was in the process of employing an additional full time senior staff member. This would enable the home to provide more consistent care.
The provider and the home's managers responded positively and swiftly to address in full all the minor concerns we raised during our inspection.
Following a recent local authority led investigation, a number of changes had been implemented. We saw the home had introduced a range of new procedures and systems to better meet people's care and welfare needs. The provider had also taken the step of not admitting anybody with more complex needs or requiring palliative care to the home, until the improved systems were embedded and staff's skills and knowledge were to the necessary level.
People, their relatives, staff and professionals involved with the service completed annual quality assurance surveys. Where shortfalls or concerns were raised these were addressed.
Is the service well-led?
Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns and investigations. This reduced the risks to people and helped the service to continually improve.
If a staff member's conduct fell below what was expected of them, we saw the provider took clear and proportionate action to address any performance issues identified.
The provider, manager and senior staff had appropriate experience of care provision and were knowledgeable about the systems and processes required for a care home's effective operation. Effective leadership meant staff followed those systems and processes, which helped to ensure people's care and support needs were met.
Staff understood their roles and responsibilities, and told us they received appropriate support and guidance from their managers.
Staff and a number of people spoke highly of a senior member of staff who had responsibility for much of the home's day to day operation. One relative, for example, told us, 'their expertise, care, judgement, I trust them implicitly. I think [the person] commands the respect of [their] colleagues.'
People chose how to occupy themselves in the service. We observed that people were spending time in the communal areas watching television and interacting with each other in the dining room. During our inspection we observed people spending time in their bedrooms listening to their choice of music and reading. We observed staff spending the majority of their time with people who used the service. They frequently checked on them to ensure they were alright when spending time on their own.
We saw staff supporting people to make their own choices about what they had for lunch and what activities they took part in. Staff knew exactly how each person communicated which meant people's wishes were understood and respected.
The provider had a system in place for obtaining and collating feedback about the quality of the service provided.
Staff that we spoke to felt very valued and supported.
One person we spoke with who lived in the home said 'I really enjoy living here, the staff are very kind, I have a lovely room and I am looked after really well'
Another person we spoke with who lived in the home told us 'The care is excellent here, I am very lucky to live here'.
We found that care plans accurately reflected people's needs and had been drawn up with their involvement and written in a person centred way.
We observed that people who lived in the home were consulted and involved in their own care.
People were supported by staff that had been recruited in a safe manner and people we spoke with said there was always enough staff available to make sure they received the care they needed.
There was an effective complaints system available. Comments and complaints people made were responded to appropriately.