Archived: Avalon Nursing Home

We also reviewed considered five compliance actions in relation to respecting and involving people who use the service, infection control, safety and suitability of premises, staffing and assessing and monitoring the quality of service provision.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

' Is the service safe?

' Is the service caring?

' Is the service responsive?

' Is the service effective?

' Is the service well led?

This is a summary of what we found:

Is the service safe?

The provider did not have an effective plan in place to manage pain. We looked at one person's care plan which identified that the person was unable to tell staff if they were in pain. We found that there was no care plan in place to manage this person's pain. We saw that pain assessment charts were in place for this person, however, records showed that these were sometimes not been completed for a period of one week, and there was no record to see if staff had assessed the person for pain in their daily records. We discussed this with the manager and clinical lead who told us that they were in the process of developing a pain management policy and would update this person's care plan to ensure effective pain management.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We found that there were enough qualified, skilled and experienced staff to meet people's needs. We discussed staffing levels with the manager for the 15 people living in the home. They told us that during the morning there was one registered nurse and four care workers on duty, one of whom was a senior care worker. During the afternoon there was one registered nurse and three care workers, one of whom was a senior care worker. At night there was one registered nurse and two care workers. Other staff included a chef, maintenance person and domestic assistants.

People who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises. We spoke with two people who told us that they felt the home was kept in a good state of repair. One person told us, "It's a nice place to live, everything works."

We found that people were cared for in a clean, hygienic environment. We took a tour of the home and noted that rooms were visibly clean and tidy. We saw that wheelchairs, commodes and bed tables were clean. We also noted that the provider had purchased new commodes for some people living in the home. We found that new light cords had been purchased and installed in people's bedrooms.

Is the service caring?

Throughout the day we observed mostly good interactions between staff and people living at the home. However, we observed some occasions where people's dignity or privacy was not respected.

During the morning we heard one person calling out in their room and we spoke with them. They told us they had dropped their drink and we could see the blanket covering their knees was wet. We saw that the person's call bell was not within their reach to enable them to call for assistance. We pressed the call bell but it was switched off after a few minutes without staff attending. We pressed the call bell again and a member of staff arrived. The member of staff pulled the blanket back moving the person's legs without telling the person what they were doing which resulted in the person becoming agitated. The member of staff then moved the pillow which was supporting the person's head without explaining what they were doing. This caused the person to become very agitated. We looked at this person's care plan which instructed staff speak to the person slowly and give them plenty of time to respond which did not happen in this instance.

Is the service responsive?

People accessed the services of healthcare professionals as required. We saw that the provider had been responsive in seeking the support from the GP and in-reach team for one person who was displaying unusual behaviours in order to protect their safety and welfare.

Is the service effective?

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. We spoke with three people who lived in the home who told us staff obtained their consent before they supported them. One person told us that they had seen their care plan and had signed it to show that they agreed with it. We saw written records that showed consent had been sought for people about; care planning, photography, the use of bedrails and medication.

We found that people were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. We noted that records relating to people who use the service were appropriately stored in a secure area and were accessible to us during the inspection.

Is the service well led?

The provider had some systems for reviewing and monitoring the quality of service provided to people, but these had not been implemented effectively to ensure that people were not at risk of unsafe or inappropriate care. We found that the provider recorded accidents and incidents and completed monthly trend analyses; however, there was no investigation into each accident, when appropriate in order to prevent reoccurrence. For example, one person obtained an injury whilst being repositioned in bed. We found no record of any investigation into this accident to ensure the safety and welfare of the person and others living in the home. We noted another accident that involved one person being injured by the footplate of their wheel chair whilst being pushed by a member of staff. There was no record of any investigation or outcome regarding this accident to prevent reoccurrence. This meant that people were at risk as there was no evidence that learning from incidents / investigations took place and appropriate changes were implemented.

' Is the service safe?

' Is the service responsive?

' Is the service caring?

' Is the service effective?

' Is the service well led?

This is a summary of what we found-

Is the service safe?

We found that where people had cognitive impairments associated with dementia, mental capacity assessments had not always been completed. We looked at the care plans for five people with dementia and found that mental capacity assessments and best interest decisions were not always recorded.

One person's care plan indicated that the person's hands had been bandaged to stop the person from scratching their skin. The person was unable to remove these and could not touch their bedclothes and was severely restricted. There was no capacity assessment in place for this person, nor was there a best interest decision recorded. There was no record of a referral in accordance with Deprivation of Liberty Safeguards (DoLS). This meant that the provider was unlawfully depriving this person of their liberty.

Care and treatment was not planned and delivered in a way that was intended to ensure people's safety and welfare. We found that care plans were not kept up to date and did not always reflect the care and treatment provided to people.

There were not enough qualified, skilled and experienced staff to meet people's needs. One member of staff told us, "We have had terrible problems with staffing recently, weekends are particularly bad. Sometimes people can do a few extra hours at the end of their shift and then we can make do without for the rest of the evening, it's not ideal but we make do."

During the second day of our inspection we noted that the home was short staffed. This meant that people most people who needed assistance to get out of bed were unable to until approximately 11am. We spoke to one person in their room who told us 'I'm still waiting for help to get up. I know they are short staffed but I don't want to cause a fuss.' We discussed this with the manager who told us that they had arranged for a member of agency staff to come to the home, however they had been delayed.

Is the service responsive?

Prior to our inspection we were alerted by the local authority safeguarding team that one person who lived in the home had not received their prescribed medicine for a period of six days. During our inspection we found that two other people had not received their medicines as prescribed. One person had not received their pain relief medication for a period of five days. Another person had not received their medicine for a period of three days. We discussed this with the manager and clinical lead who told us that there had been on-going issues with the pharmacy, however acknowledged that staff had not acted appropriately in chasing the prescriptions. This meant that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

We found that the provider did not always have regard to professional advice given. Prior to our inspection we were contacted by the local authority service improvement team. They told us that the provider had not taken appropriate action to address a list of improvements that they had requested. We discussed this with the provider during the inspection, who acknowledged that they had lost the report, but were in the process of implementing the requested improvements.

Is the service caring?

People we spoke to and their relatives told us that the staff were caring. One person told us 'The staff are nice, no problems there'. Another person told us 'They get me up, wash me, feed me, I don't have to do anything.' A relative told us, 'There is a lovely family atmosphere here and staff and visitors all know each other. The staff are kind. They put themselves out for people'.

However we found that during lunchtime people were not always supported in a dignified manner. For example, where people required assistance to eat, we saw that staff were sometimes talking to each other rather than focusing on assisting the person.

Is the service effective?

People were not cared for in a clean, hygienic environment. We found that some of the rooms and equipment in the home were dirty. The provider did not have an effective system in place to ensure that the home was kept clean.

People were not supported to be able to eat and drink sufficient amounts to meet their needs. We looked at the care plan for one person. We noted that they had not been weighed and their Malnutrition Universal Screening Tool (MUST) was incomplete. This meant that the person was not protected against the risks of inadequate nutrition. The records for another person stated that they were underweight. We saw that they were recorded as being at "high risk" of malnutrition. We looked at this person's food chart and saw that over the past two days they had been given food to eat at the main meal times of breakfast lunchtime and dinner, but no additional snacks to increase their nutritional intake. We noted that they had eaten all of the food given to them. This person had not received any professional guidance to investigate their weight loss, and none of the food and fluid records seen included fortified meals or supplement drinks. This meant that appropriate action had not been taken to follow up on this person's weight loss and they were not protected from the risks of inadequate nutrition and hydration.

We looked at the fluid charts for seven people at risk of dehydration who lived in the home. We found that most of these contained no targets. This meant that staff would not know whether people had received enough fluid to meet their needs and people were at risk of inadequate hydration.

Is the service well led?

We found that the home had some systems for reviewing and monitoring the quality of service provided to people. These had not been implemented effectively to ensure that people were not at risk of unsafe or inappropriate care in a way that protected people from harm.

The systems that the provider had in place, had not identified the shortfalls we found during the inspection.

We found that many of the records that the service used had been poorly photocopied which meant that they were illegible. Some records relating to people's care were incomplete. Records were not always kept securely and could not be located promptly when needed.

We found that the provider had complied with the compliance action issued, which required the service to have an effective system to regularly assess and monitor the quality of service that people received. We also found the provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

People living at Avalon were positive about their experience of living at the home. No one had any complaints or concerns about how the home was run and managed. One person told us "its fine, it's great".

People told us that they had good relationships with the staff who were described as "nice and respectful". People told us that there were regular activities and the standard of food was good.

People who used 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.

Staff were supported to deliver care and treatment safely and to an appropriate standard.

We found the home had a quality assurance system in place to ensure standards in the home were maintained.

People living at Avalon were very positive about their experience of living at the home. No one had any complaints or concerns about how the home was run and managed.

People told us that they had good relationships with the staff, who were described as 'very good'. They told us that the home was kept clean and warm. People said there were activities to keep them occupied.

People told us that they were involved in decisions about how they were looked after and that they could choose how they wished to spend their day.

People who lived at Avalon benefited from thorough processes and procedures being followed when new staff are recruited, which meant they were protected from harm.

Medicines were prescribed and given to people appropriately.

We found the home did not have a robust quality assurance system in place to ensure standards in the home were maintained.