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Inspection carried out on 8 August 2019

During an inspection to make sure that the improvements required had been made

About the service:

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 23 people. 23 people were using the service. This is larger than current best practice guidance. However. the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other large domestic homes of a similar size. There were deliberately no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

What life is like for people using this service:

People who live at Royal Avenue have their needs met by sufficient numbers of suitably trained staff. People told us staff were kind to them.

There were appropriate risk assessments in place to guide staff on how to reduce risks to people. These had been recently updated to a new format which was clearer for staff. There was sufficient information in people’s care plans about how risks should be mitigated to protect people from harm.

The service understood how to safeguard people using the service from the risk of abuse. Where required, there were specific plans in place for safeguarding people who accessed the community independently.

Medicines were monitored, managed and administered safely. The service was clean and plans were in place to limit the potential spread of infection.

Appropriate action was taken by the service in response to incidents and accidents to reduce the risk of recurrence.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update):

At the last inspection the service was rated Good (report published 1 November 2018).

Why we inspected:

We received concerns in relation to the management of people’s falls risk. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.

The overall rating for the service has remained the same. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Royal Avenue on our website at www.cqc.org.uk.

Follow up:

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection carried out on 20 September 2018

During a routine inspection

Royal Avenue is a care ‘home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Royal Avenue is a care service for up to 23 people who have a learning disability. The service does not provide nursing care.

There were 22 people living in the service when we inspected on 20 September 2018. This was an unannounced inspection.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.” Registering the Right Support CQC policy

The service supports people with regard to a personalised needs assessment and resulting care plan to meet their current needs and staff worked with people to develop their skills to pursue the person’s individual goals.

There was a registered manager in post. 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.

At our last inspection of 13 October 2016, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service did not have an effective quality assurance monitoring process in place. There were no policies and procedures regarding the Mental Capacity Act 2005 (MCA) and no records that people had consented to the care provided.

In the key questions for safe, effective, responsive and well-led we rated the service as ‘requires improvement’. In the key question for care we rated the service ‘good’. This resulted in the overall rating of the service for that inspection being ‘requires improvement’.

At this inspection of 20 September 2018, we noted there have been improvements to the service and the overall rating has improved to ‘good’. There were no breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In the key question for safe, effective and responsive the rating has improved to ‘good’ and care remains ‘good’ but well-led is still rated as ‘requires improvement’.

The formal monitoring and audit systems now in place continued to require further operational evidence. This would then show how the registered manager and senior staff assessed the quality of the service, identified shortfalls and ensured that these were addressed promptly. Although there was clear evidence of monitoring the cleanliness of the service. The formal recording of staff supervision and training was incomplete and care plans had not always been checked that they were up to date.

Care staff had spoken with and recorded people’s wishes and consent to their care. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in relation to the MCA were up to date.

People were appropriately supported to take their prescribed medicines

There were sufficient numbers of staff employed at the service to support the people living in their home. The staffing rota was clear with regard to which staff were working. The registered manager and staff on duty were cooking the meals for people either in a group setting or on a one to one basis.

The recruitment process for the employment of staff was clear and safe procedures were followed.

People were encouraged to attend appointments with health care professionals to maintain their health and well-being.

Part of the service was being refurbished and people informed us that

Inspection carried out on 13 October 2016

During a routine inspection

Royal Avenue provides accommodation, care and support for a maximum of 23 people who have a learning disability. There were 23 people using the service when we inspected on 13 October 2016.

There was a registered manager in post who was also the provider of the service. 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.

Our previous inspection of 17 February 2015 identified that improvements were needed with regard to effective quality monitoring systems and monitoring of complaints. We also identified that the assessment of people’s capacity to consent to care and treatment was not being undertaken in line with the Mental Capacity Act, and care plans required more detailed information to reflect individual needs and preferences. We found areas of practice that needed to improve, including protecting people's dignity and maintaining professional boundaries.

We undertook a comprehensive inspection on 13 October 2016 to check whether action had been taken to address the breaches previously identified. Improvements had been made in some areas. However, we found continued breaches in relation to consent and governance of the service.

Whilst the service had made reference to people’s ability to consent within their care records, there were no formal capacity assessments in place to determine people’s level of understanding in accordance with the MCA. Staff understanding of what the MCA meant in practice was limited.

There were improved processes in place to monitor the quality and safety of the service provided and to understand the experiences of people who lived at the service. However, the management team needed to improve how they analysed the information to implement change.

A complaints procedure was in place, however, actions taken in response to feedback was not always recorded, which meant the management team did not have effective oversight and were not therefore able to monitor trends and recurring themes.

Care plans contained detailed information including people’s preferences, their preferred routines, life histories, and hobbies and interests. Risk assessments were in place. However, these needed to be more comprehensive in relation to how risks were managed between people living in the service.

Procedures were in place which safeguarded the people who used the service from the potential risk of abuse. Staff understood the various types of abuse and knew who to report any concerns to.

Safe recruitment procedures were in place, and staff had undergone recruitment checks before they started work to ensure they were suitable for the role.

Inspection carried out on 17 February 2015

During a routine inspection

We inspected this service on 17 February 2015. Royal Avenue provides accommodation, care and support for a maximum of 23 people who have a Learning Disability. There were 23 people living in the service when we inspected.

There was a registered manager in post who is also the provider of the service. 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.

Procedures were in place which safeguarded people from the risk of abuse. Care staff understood the various types of abuse and knew who to report any concerns to.

The provider had systems in place which ensured the safety of the people living in the home. These included assessments which identified how risks to people were minimised. However, some of these documents had not been completed in respect of recently admitted people who had identified needs around behaviour which challenged others.

Where people required assistance to take their medicines appropriate arrangements were in place to provide this support safely.

People were supported by sufficient numbers of staff who were trained and supported to meet their needs.

People, or their representatives, were involved in making decisions about their care and support, and spoke positively about the quality of care they received, and the impact this had had on their lives.

Staff ensured people were provided with choices in all areas of daily living. However, where people had little or no communication the manager had failed to assess their capacity to consent to care and treatment. This placed people at risk of receiving care or treatment they did not consent to.

People liked the food and were able to choose their meals.

Where people had been identified as losing weight, staff had taken action to refer people to the appropriate agencies However; staff had failed to keep an accurate record of people’s food intake. There were no clear plans in place to inform staff of what action they needed to take to help people reach and maintain a healthy weight id this was an identified need.

Staff interacted with people in a caring and professional manner. People and staff had developed positive and meaningful relationships. However, further guidance and training is required to ensure that appropriate boundaries are maintained in relationships between people, the staff and the managers of the service. People spoke positively about their experiences since moving in to the home, and showed signs of improved outcomes in their physical, social, emotional and psychological health.

We observed that staff were mindful of respecting people’s privacy and dignity when providing care and support. However, information received after the inspection took place led to an investigation by the local authority which concluded that staff required further training in how to promote people’s independence and uphold their dignity and respect.

People were confident they could share any concerns they had about the home with the manager. However, the manager had failed to produce clear records of their investigations into, and the outcomes of complaints.

Care plans contained some detailed information about people’s needs; but these had not been reviewed or updated to reflect current needs

The manager had been in post since the home first opened. Staff told us that the manager was knowledgeable, and inspired confidence in the staff team and led by example. Staff understood their roles and responsibilities in providing safe and good quality care.

People held the manager in high regard and felt confident in their ability to resolve any concerns they had. However, we identified a lack of systems in place to assess and monitor the quality of the service, which meant areas for improvement and issues that placed people at risk of receiving poor care were potentially missed.

We found a number of breaches of the Health and Social care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

Inspection carried out on 14 April 2014

During a routine inspection

Mrs P Barnard is the owner of Royal Avenue which is a care home providing accommodation for a maximum of 19 people with learning disabilities. There were 19 people living there when we visited. Mrs Barnard is also the registered manager for the service. We spoke with six people who told us that they were happy living at the service and that the staff were kind and caring.

Staff had access to safeguarding adult’s policy and procedure in place. Staff had a good understanding of the procedures and how and when to follow it.

The management team worked hard to develop crisis behaviour management plans for managing behaviour that challenges. Staff used this guidance to ensure that people’s behaviour was dealt with effectively and in a manner that respected their dignity and protected their rights.

Policies and procedures were in place that ensured staff had access to guidance on how to promote people’s privacy, dignity, independence and human rights. We observed that staff adhered to these principles during our inspection, recognising the diversity, values and rights of the people that used the service.

People were receiving care and support that promoted a good quality of life. People’s preferences and needs were recorded in their care plans and saw that staff were following these plans in practice.

People’s nutrition and hydration needs were assessed and monitored to ensure that they received a diet that maintained their health. People told us that they always had several choices and snacks were always available. People had access to food and drink of their choice when they wanted it.

Documents showed that mental capacity assessments and best interests meetings had taken place, when decisions needed to be taken on behalf of someone who was deemed to lack capacity. This meant that the service understood the requirements of the Mental Capacity Act (MCA) 2005 and put them into practice to protect people.

We found the service was meeting the requirements of the Deprivation of Liberty Safeguards. We observed people were able to come and go from the service when they wanted to, without unnecessary restrictions placed on them.

We found that the management and leadership of the service ensured that staff delivered high quality care which was centred on the needs of the people living at Royal Avenue. Our observation of the interaction between people who used the service and staff were positive. Records we looked at, confirmed that people’s care was individually led by well trained staff.

The provider had safe recruitment processes in place that ensured staff had the right skills and experience to support the people who used the service. We looked at the staffing arrangements, including the staff working rota’s and found that there were enough staff on duty with the right competencies, knowledge, skills and experience to keep people safe.

Systems were in place that enabled open communication between the people that used the service, their relatives, managers and the staff. Residents meetings took place on a regular basis so that people were able to have their say about how the service was run, and talk about things that mattered to them. The minutes of staff meetings showed that staff had the opportunity to discuss issues about the service in an open and transparent way.

Inspection carried out on 23 October 2013

During a routine inspection

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The three people we spoke with told us that they were happy with the care and support that they received. One person said, “I‘ve got a very good home. I love it”. The service promoted independence and provided a range of activities and outings to suit people of different ages.

Care plans were clear and contained a range of information about the people and their care needs. Daily notes and medication records confirmed that care and support was provided in line with the care plans. However, some of the information in the care plans that we looked at was out of date.

There was a medication policy supported by procedures that detailed how medication was to be stored and handled. We saw that the procedures were correctly followed, protecting people against the risks associated with medicines.

People were cared for and supported by suitably qualified, skilled and experienced staff. Appropriate recruitment checks were made.

At the time of our inspection the ages of the 19 people being cared for ranged from late teens to people in their 70s.

Inspection carried out on 23 May 2012

During a routine inspection

People using the service told us how happy and content they were. They liked the staff, and they liked being able to decide how they spent their time. They said that staff looked after them well.

Reports under our old system of regulation (including those from before CQC was created)