Avalon Care Home

The care home has two floors. The ground floor has become a communal area for younger people and people with a learning disability.

People’s experience of using this service and what we found

Governance and quality assurance systems had improved since our last inspection. People said they felt safe, and risk assessments were clearly written and reviewed. Medication was administered safely by staff who were trained to do so. Some people were supported and encouraged to administer their own medication where able. Accident and Incident logs had improved since the last inspection, therefore opportunities to mitigate risk were identified.

Infection control prevention was improved, and the home looked and smelled cleaner. There were enough suitably qualified staff to support people, however some people told us they could not always go out and about due to lack of staff.

Safeguarding systems and policies were in place and staff could describe the action they would take if they felt people were at risk of abuse.

People were supported to follow modified diets and had choice and control over what food was served. Staff were undertaking training courses, most staff had been trained, however there were some gaps in staff training records. This was due to new staff starting. Staff had been supervised and appraised.

Staff and people living at the home liked the registered manager and felt they had made good progress since the last inspection. The registered manager understood their duty to share information in an open and honest manner.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support: People were supported to have maximum choice and control of their lives and staff did support them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Right Care: Although we found gaps in the support and culture, staff were very caring in nature and upheld people’s dignity and privacy. Care plans were written respectfully and put the person at the centre of their care.

Right Culture: Although staff and managers had values to support people to lead confident and inclusive lives, the environment of the home made this difficult. Younger people who had a learning disability lived within a care home environment, meaning opportunities for choice and control were limited. It was difficult for staff to meet the needs of everyone, due to a wide range of service user groups, with different sets of guidance for staff to follow.

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

The last rating for this service was inadequate (published 16 November 2022).

Why we inspected

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider was no longer in breach of regulation.

This service has been in Special Measures since 16 November 2022. During this inspection the provider demonstrated that some improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements. We also checked whether the Warning Notice we previously served in relation to Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Inadequate to Requires Improvement. 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 Avalon Care Home on our website at www.cqc.org.uk.

Follow – up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Avalon Care Home is a residential care home providing personal care for up to 26 people. The service is registered to provide support to people living with dementia, people with a learning disability or autistic spectrum disorder, people with mental health needs, people with a physical disability and or sensory impairment, and younger adults. There were 23 people living at the care home at the time of the inspection.

The care home has two floors and are adapting the ground floor to become a communal area for younger people and people with a learning disability.

People’s experience of using this service and what we found

During the inspection we found that people did not always receive safe care and treatment. Clinical risks to people were not always assessed or monitored and people did not always receive their medicines safely. Records did not adequately guide staff on what actions to take. Staff shared safeguarding concerns with the local authority although their processes for monitoring this required improvement. There were cleaning schedules in place although some areas were cluttered. People told us they felt well cared for living at the home. A relative said, “I feel that my relative gets safe care.” We made recommendations about the safeguarding processes and learning lessons if things go wrong.

Although staff training was up to date, further training in managing clinical needs was required, which we have made a recommendation about. People were not always supported to give consent about their care and treatment in a lawful way. Although people had access to healthcare facilities, staff did not always involve external professionals to make sure people’s care and treatment was co-ordinated and consistent.

The provider did not make sure there was effective governance to protect people from risks and promote safe and high-quality care. Managers did not always identify problems or concerns and therefore they missed opportunities to improve the safety of care and treatment people received.

Staff spoke positively about their roles and told us they felt supported by their managers. People and relatives spoke highly about the care, one person said, “It is a really, really good care home.” We found that people and relatives were involved in their care planning and managers kept in regular contact with relatives.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support: People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Right Care: Although we found gaps in the support and culture, staff were very caring in nature and upheld people’s dignity and privacy. Care plans were written respectfully and put the person at the centre.

Right Culture: Although staff and managers had values to support people to lead confident and inclusive lives, the environment of the home made this difficult. Younger people who had a learning disability lived within a care home environment, meaning opportunities for choice and control were limited. It was difficult for staff to meet the needs of everyone, due to a wide range of service user groups, with different sets of guidance for staff to follow.

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

The last rating for this service was requires improvement (published 19 March 2022).

Why we inspected

The inspection was prompted in part due to concerns received about infection control, record keeping and timely requests for medical input. A decision was made for us to inspect and examine those risks. We undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to medicines management, managing risk, consent to care and treatment and the overall governance of the service at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Avalon Care Home is a residential care home providing personal care for up to 26 people. The service provides support to adults aged over 18, including people with a learning disability and or autism. At the time of our inspection there were 26 people using the service. The home is set over three floors, and these are accessible via a lift. There are two communal lounges and a dining area.

People’s experience of using this service and what we found

Not all risks and concerns were identified or managed with effective systems.

We have made recommendations about the management of medicines and Mental Capacity Assessments.

Staff had good knowledge of people’s needs, likes and dislikes. A relative told us, “The staff are caring and kind and know (the person) well.” The home was clean and tidy; one relative said, “It is always nice and clean. They change (the person’s) bedding daily.”

People’s needs were assessed, and they were supported by staff that had the right training, skills and experience.

People were positive about the menu and one person told us they loved the food. People could decorate their room how they liked and the home made changes to make sure people were comfortable.

There were some gaps in the overall governance of the service. However, we found a positive culture amongst managers and staff which benefitted the people who lived at Avalon Care Home. Senior managers engaged well with others and responded to feedback quickly to make improvements to the care given.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of safe, effective and well-led, whilst the service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture, we were not assured about systems and processes which support good governance.

People were supported to have choice and control and staff encouraged independence. Adaptations were being made so that people with a learning disability could have appropriate spaces within the home which met their needs.

Care was person centred and promoted dignity, privacy and human rights. Care plans reflected the holistic needs of people and were written respectfully and with people at the centre.

Managers and staff had values which made sure that people using the service were empowered to live confident and positive lives. Staff worked alongside other professionals to make sure they had the necessary knowledge and skills to support people in an inclusive way. People had the opportunity to gain skills such as cooking and gardening.

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

Rating at last inspection

The last rating for this service was good (published 8 May 2019).

Why we inspected

We received concerns in relation to the management of safeguarding issues. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the governance of the service at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Avalon EMI Care Home is a residential care home that was providing personal and nursing care to 18 people aged 65 and over at the time of the inspection.

People’s experience of using this service:

Following the last inspection, we met with the provider to confirm what they would do and by when to improve the key questions Effective and Well Led to at least good. We asked the provider to take action to make improvements to monitoring staff training and to mental capacity assessments, and this action has now been completed.

People told us that they felt safe living at the service. Care records provided detailed information around people's individual risks in order for staff to keep them safe from avoidable harm. Person centred care was delivered, giving people choice over their daily routines in line with their preferences.

Staffing levels were appropriately managed and people received care from consistent, regular staff. Enough staff were employed each day to meet people's needs and keep them safe. Our observations during the inspection showed that care was provided in a safe manner and staff were available when people required support.

Recruitment processes were robust. The necessary pre-employment checks were completed, and people received care from staff who were suitable to work in adult social care environments.

Processes and systems were in place to ensure people received their medicines when they needed them, from trained and competent staff.

People's overall health and well-being was effectively assessed and managed. Referrals were made to external healthcare professionals accordingly.

People made positive comments about the food they received. Menus offered a variety of home-made and fresh meals each day. People received support to eat their meals when they needed it.

People were supported in a kind, caring and compassionate manner. Staff were familiar with the support needs of the people they were supporting. Staff engaged in meaningful conversations with people to provide stimulation and reassurance.

The registered provider had a complaints policy in place. No complaints had been made since the last inspection.

People were encouraged to participate in a programme of activities.

The home was clean and hygienic. Health and safety measures were in place to ensure people lived in a safe, well-maintained environment.

More information is in Detailed Findings below

Rating at last inspection: Requires Improvement (Report published October 2018). At this inspection we found the overall rating had improved.

Why we inspected: We were due to inspect the service in October 2019, based on the rating of the previous inspection. However, the inspection was brought forward due to information of concern we received regarding low staffing numbers.

Follow up: No concerns were raised within this inspection. We will therefore aim to re-inspect this service within 30 months. We will continue to monitor the service through the information we receive. If any concerning information is received we may inspect sooner.

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

Avalon is a care home that provides personal care and support for up to 26 people living with dementia. There were 22 people in the home during our inspection.

Avalon 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. Avalon accommodates people in one adapted building. The home is set in a residential area of Southport, close to the town centre. A lift provides access to all floors and there are two separate communal areas. There is a well-kept garden area to the front and side of the building.

Avalon was previously inspected in December 2017. During the inspection we found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that when people were unable to consent, the service had not always followed the principles of the Mental Capacity Act 2005. This was because an assessment of the person’s mental capacity was not always decision specific.

Following the last inspection on 13 December 2017, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Is the service Effective, to at least good.

The home 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.

At the last inspection on 13 December 2017, we asked the provider to take action to make improvements to the completion of mental capacity assessments. At this inspection we found the service continued to require improvement in the understanding and use of the Mental Capacity Act 2005. We found issues in the way the service applied principles of the MCA. Completed assessments were not ‘decision specific’. Managers still showed a lack of understanding of the Mental Capacity Act. This was a continued breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Quality assurance audits were completed by the manager and deputy manager which included, medication and health and safety. However, issues found during the inspection had not been identified as part of this process.

This is the second, consecutive time the service has been rated Requires Improvement.

You can see what action we told the provider to take at the back of the full version of the report.

Everyone who lived in the home said they felt safe. There were robust measures in place to ensure people were safe. Risk assessments were in place for areas such as pressure care, falls and mobility, and nutrition and hydration.

Safeguarding systems processes and practices helped staff to understand how to protect people from abuse, neglect, harassment and breaches of their dignity and respect.

There were sufficient staff on duty to meet people's needs. Staff rotas showed a consistent number of staff were on duty each day. People told us call bells were answered within a reasonable time. This helped to evidence there were enough staff to support people safely.

Staff had been appropriately recruited to ensure they were suitable to work with vulnerable adults.

Medicines were managed safely and people received their medicines as prescribed. Staff had been trained to administer medicines to ensure their competencies and keep errors to a minimum.

The home was very clean and there were no odours. Personal protective equipment (PPE) such as aprons and gloves were available and used when supporting people with personal care and administering medication.

The home was well maintained and in good decorative order. People's bedrooms were personalised and were decorated and furnished to a high standard.

At our last inspection we made a recommendation regarding the home’s environment. This was to improve the design and adaptation of the premises with respect to meeting the needs of people living with dementia. At this inspection we found the service had made some positive changes to the premises.

People were visited by GPs and district nurses regularly. However, we found that health-related care plans, recording and processes were not always clear and robust. This could put the health particularly of residents with vulnerable skin at risk. The registered manager was looking to make further improvements.

We made a recommendation regarding this.

We found that staff had the skills, knowledge and experience to support people effectively and safely. Staff were supported by the registered manager through regular supervisions, annual appraisal and regular training.

People were supported to eat and drink enough to maintain a balanced diet and meet their dietary requirements. Drinks were offered at various times throughout the day to ensure people's hydration needs were met.

Everyone living in the home was very complementary about the attitude of the staff and the way they were treated. We observed staff speaking to people respectfully; they were extremely patient.

Staff knew people and understood their different communication needs. Staff supported people to make decisions about their care, support and treatment as far as possible. Records showed people's preferred routines, likes and dislikes.

There was an activity coordinator in post. The programme of activities included one to one time with people as well as group activities such as exercises, games, crafts and musical entertainers.

People living in the home and relatives were able to share their views and were able to provide feedback about the service. Feedback on inspection from people in the home and relatives was very positive regarding the care provided.

Staff were aware of the need to support people approaching the end of their life and care planning arrangements were person centred to ensure their wishes and needs were respected.

There was a caring, person-centred, and open culture in the home. The provider and registered manager met their legal requirements with the Care Quality Commission (CQC). They had submitted notifications to us in accordance with our regulation and the ratings from the last inspection were displayed in the home and on the registered provider's website.

Further information is in the detailed findings below.

The service was last inspected in October 2015 and was rated ‘Good’ at that time. This is the first time the service has been rated ‘Requires Improvement’.

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.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed in that an assessment of the person’s mental capacity was made. When people were unable to consent, the principles of the Mental Capacity Act 2005 were not always followed in that an assessment of the person’s mental capacity was not always made with reference to specific key decisions.

You can see what action we told the provider to take at the back of the full version of this report.

We found the design and adaptation of the premises could be further improved with respect meeting the needs of people living with dementia.

We made a recommendation regarding this.

The manager and senior managers for the provider were able to evidence a range of quality assurance processes and audits carried out at the home. We found quality assurance systems needed further developing in line with providing further good practice for people living with dementia.

We made a recommendation regarding this.

We found medicines were being safely managed. Key staff were responsible for monitoring and administering medicines. The administration records for some medicines such as prescribed ‘thickeners’ for drinks (for people with swallowing difficulties) could be further improved.

We looked at how staff were recruited and the processes to ensure staff were suitable to work at Avalon EMI care Home. We saw required checks had been made to help ensure staff employed were ‘fit’ to work with vulnerable people. We found there were sufficient staff on duty to meet people’s care needs.

People’s clinical care was assessed for any risks and organised so plans were put in place to maximise people’s independence whilst help ensure people’s safety.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. Training records confirmed staff had undertaken safeguarding training in-house. Not all of the staff we spoke with were clear about the wider issues around ‘safeguarding’ people and this was feedback to the registered manager to inform future training.

Arrangements were in place for checking the environment to ensure it was safe. Health and safety checks were completed on a regular basis so hazards could be identified. Planned development / maintenance was assessed and planned well so that people were living in a comfortable and safe environment. The home was clean and there were systems in place to manage the control of infection.

Staff said they were supported through induction, appraisal and the home’s training programme. People we spoke with and their relatives felt staff had the skills and approach needed to ensure people were receiving the right care.

We found the home supported people very well to provide effective outcomes for their health and wellbeing. We saw there was regular and effective referral and liaison with health care professionals when needed to support people. Feedback from visiting health care professionals we spoke with was positive.

People we spoke with said they were happy living at Avalon EMI Care Home. Staff interacted well with people living at the home and they showed a caring nature with appropriate interventions to support people. We found a caring ethos throughout the service.

People told us their privacy was respected and staff were careful to ensure people’s dignity was maintained. We highlighted some issues, however, around the display of personal information and staff sometimes used inappropriate terms when referring to people who required assisted feeding. This was acknowledged and addressed by the registered manager.

We saw people’s dietary needs were managed with reference to individual preferences and choice. Lunch time was seen to be a relaxed and sociable occasion.

People felt involved in their care and there was evidence in the care files to show how people and / or their relatives had been included in planning and reviews of their care.

Social activities were organised in the home and continued to be developed. People told us they could take part in social events which were held.

We saw a complaints procedure was in place and people, including relatives, we spoke with were aware of how they could complain.

The manager was aware of their responsibility to notify us [The CQC] of any notifiable incidents in the home.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People who lived at the home and their relatives and visitors told us they were treated with respect and dignity by the staff. They told us care was good and if they had any medical issues that needed monitoring, or to be followed up, this was arranged. People told us they felt safe and well cared for.

Systems were in place to make sure that the home was maintained safely with respect to health and safety issues. We saw that gas, fire, water and electrical safety were continually monitored.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. We were told about one application that had been made. This showed that the service understood the process involved. The home had also introduced an assessment for measuring people's mental capacity in terms of individual decisions that might need to be made. However, we found that these assessments were not very clear. For example one part of the assessment for a person seemed to show the person had capacity to make decisions but further on it was recorded that staff seemed to be acting in the person's best interest and making decisions for them. We discussed this and the manager said she would review the assessment form to make it clearer.

Is the service effective?

People's health and care needs were assessed. Specialist dietary needs had been identified where required. From reviewing the care of people we saw that the care being carried out reflected their current needs.

People told us that staff asked them about their care and they felt involved.

One relative told us, 'I can't fault the place ' it's excellent and I've just completed one of their surveys to tell them.' another said, 'The care is very personalised, very person centred.' When we asked what they meant by this we were told that staff spent time thinking about each person separately and what was best for them as people.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People commented, 'The staff are very good and the food is good. I'm fine.', 'There's lots to do. They [staff] put films on regularly ' some good ones too', 'I've been settled since I've been here, the staff have really sorted me out' and 'We do different sorts of activities. It's very good. We get to choose whether we join in.'

People said staff did everything needed to support them with their day to day living.

We observed staff continually working to support people with all aspects of care. We observed staff communicating and interacting well whilst supporting people. We saw one example where care was not carried out as effectively as it could have been and we fed this back to the manager.

People's preferences and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

We saw that people were supported to complete a range of daily activities and this included support with social activities. Social activities were organised on a daily basis and we saw examples of people being actively engaged and involved throughout the day of our inspection.

People were supported as their care needs changed. This was particularly evident with two people who had changing needs concerning support with their diet.

We found that any issues identified by the home's systems of monitoring were addressed and the improvements made. For example the way food and drinks were organised in the morning had recently been reviewed. The home's manager had a range of easily accessible information to help monitor and plan any changes needed to improve the service.

Is the service well-led?

The service had a quality assurance system. This included both internal and external audits [checks]. The system of audits helped support the manager to run the home effectively. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes that were in place. This helped to ensure that people received a good quality service at all times.

People who were able to give an opinion told us they were happy with the care and support they received. Their comments included, 'I know I can see my doctor when I need to and the staff will organise this.' We spoke with a relative of a person living at Avalon who told us that their relative had settled well and was being well cared for. They commented, ' [Person] was previously isolated but she is happy here and talks to the other residents.' People felt their privacy and dignity were respected.

Further improvements included monitoring infection control and people were protected from the risk of infection because appropriate guidance had been followed.

We also saw that the service have recruited extra staff and there were enough qualified, skilled and experienced staff to meet people's needs.

We found that people were listened to so that any concerns could be addressed. The manager said she would ensure that the current complaints process was better advertised in the home.

We received positive comments from people we spoke with about the staff. Comments included: 'Staff are approachable and they explain everything to me.' We spoke with health care professionals visiting the home who said that staff liaised well and appeared knowledgeable regarding the people living at Avalon.

We identified a period during the morning where there were not enough qualified, skilled and experienced staff to meet people's needs. This compromised the care of vulnerable people and exposed them to unnecessary risk.

People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

The laundry area was not being effectively monitored and there were some practices which increased the likelihood of cross infection.