Archived: Avalon Nursing Home

Updated 9 March 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 13, 22 and 23 October 2014 and was unannounced. There were two inspectors in the inspection team. We spoke with and met eight people living at Avalon Nursing Home. Because some people were living with dementia we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We spoke with three visiting relatives during the inspection. We also spoke with the manager, clinical compliance executive matron, training manager and four staff.

We looked at five people’s care and support records, an additional two people’s care monitoring records, medication administration records and documents about how the service was managed. This included staffing records, audits, meeting minutes, training plans, maintenance records and quality assurance records.

Before our inspection, we reviewed the information we held about the service. This included the information about incidents the provider had notified us of.

We did not ask the provider to complete a Provider Information Return (PIR) before our inspection. This is a form that asks the provider to give us some key information about the service, what the service does well and improvements they planned to make. This was because we had planned to carry out a focussed inspection to follow up breaches of the regulation identified at the last inspection. However due to the shortfalls identified on 13 October, we returned on 22 and 23 October 2014 to gather further information and completed a full inspection at the home.

Updated 9 March 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, and to provide a rating for the service under the Care Act 2014.

This was an unannounced inspection carried out on 13 and 22 and 23 October 2014. At the last inspection in August 2014 we found a breach of regulations relating to the care and welfare of people, respecting and involving people and assessing and monitoring the quality of service.

An action plan was received from the provider which stated they would meet the legal requirements by 30 September 2014.

At this inspection we found they had failed to make improvements. We have taken enforcement action against Avalon Nursing Home to protect the health, safety and welfare of people using this service.

Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service (and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

Avalon Nursing Home is registered to provide personal care for up to 18 people. Nursing care is provided. There were 17 people living at the home when we inspected. There was no registered manager in place at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

Staff did not always treat people with dignity and respect. Staff knew people’s care needs and some personal information about them. We saw good relationships and interactions between some staff and people.

People’s need for social stimulation, occupation and activities were not consistently met.

People’s care and monitoring records were not consistently maintained and we could not be sure they accurately reflected the care and support that people needed and was provided to people.

There were poor arrangements for the management and administration of medicines that put people at risk of harm. One person did not receive their medicine as prescribed by their GP.

Staff did not have the right skills and knowledge to provide personalised care for people living in the home. This was because they did not always receive a full induction into care, the right training or regular support and development sessions with their managers.

The provider did not always comply with the Mental Capacity Act 2005, which included how to assess people’s capacity to make specific decisions.

Policies about keeping people safe and reporting allegations of abuse were generic and we found one instance where the safeguarding policy had not been followed. Staff training records indicated that not all staff had received safeguarding training

The systems and culture of the home did not ensure the service was well-led. This was because people were not encouraged to be involved in the home, they were not consulted, staff were not consulted and the quality assurance systems in place did not identify shortfalls in the service.

Staff were recruited safely to make sure they were suitable to work with people. There were regular staff meetings and handovers to share information between staff.