Avalon Nursing Home

Avalon Nursing Home provides nursing and personal care for up to 38 older people, some of whom were living with a dementia type illness. There were 32 people living at the home at the time of the inspection. In addition to living with dementia people had a range of complex health care needs which included stroke and diabetes. Most people required help and support from two members of staff in relation to their mobility and personal care needs.

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

Systems and processes to assess, monitor and improve the quality and safety of the service provided were in place. However, there were areas of people’s documentation that needed to be improved to ensure staff had the necessary up to date information to provide consistent, safe care. Staff practices regarding medicine practices needed to be further developed to ensure that staff follow the organisational policy for safe administration of medicines. Oral health was found not be consistently monitored to ensure good practice was consistently followed.

People received safe care and support from staff who had been appropriately recruited, trained to recognise signs of abuse or risk and understood what to do to safely support people. One person said, “I feel as if I get good care, I do feel comfortable here.” A visitor told us, “My relative is happy here, the staff are very good with her, we are pleased with the care.” People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible. There were enough staff to meet people's needs, but staff deployment at busy times needs to be reviewed. Safe recruitment practices had been followed before staff started working at the service.

The provider and registered manager were committed to continuously improve and had developed structures and plans to develop and consistently drive improvement within the service and maintain their care delivery to a good standard.

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 Good (published 4 February 2020)

Why we inspected

This inspection was prompted due to information of risk and concern in relation to staffing levels, communication and safeguarding concerns which had impacted on care delivery. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

The concerns raised were looked at during this inspection and have been reflected in the report.

We have found evidence that the provider needs to make improvements. Please see the well-led question 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.

Follow up:

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

Avalon Nursing Home provides nursing and personal care for up to 38 older people, some of whom were living with a dementia type illness. There were 27 people living at the home at the time of the inspection. In addition to living with dementia people had a range of complex health care needs which included stroke and diabetes. Most people required help and support from two members of staff in relation to their mobility and personal care needs.

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

Systems and processes to assess, monitor and improve the quality and safety of the service provided were in place. However, there were areas of people’s documentation that needed to be improved to ensure staff had the necessary up to date information to provide consistent, safe care. Whilst care plans identified a care need, there was a lack of clear guidance and changes to care needs were not clearly defined.

People received safe care and support from staff who had been appropriately recruited, trained to recognise signs of abuse or risk and understood what to do to safely support people. One person said, “Home from home here, very safe here, I get on with everybody so that helps.” A visitor told us, “Very safe here, the staff are kind and caring; they treat her with dignity and respect.” People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible. Medicines being given safely to people by trained and knowledgeable staff, who had been assessed as competent. There were enough staff to meet people's needs. Safe recruitment practices had been followed before staff started working at the service.

Staff had all received training to meet people’s specific needs. During induction, they got to know people and their needs well. One staff member said, “I love working here, I have done lots of training.” People’s nutritional and health needs were consistently met with involvement from a variety of health and social care professionals.

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.

Everyone we spoke to was consistent in their views that staff were kind, caring and supportive. One person said, “It is a safe place for me, it is the support I get emotionally and physically.” People were relaxed, comfortable and happy in the company of staff. People’s independence was considered important by all staff and their privacy and dignity was promoted.

Staff were committed to delivering care in a person-centred way based on people's preferences and wishes.

There was a stable staff team who were knowledgeable about the people they supported and had built

trusting and meaningful relationships with them. Activities met people’s preferences and interests. People were encouraged to go out and form relationships with family and members of the community. Staff knew people’s communication needs well and we observed them using a variety of tools, such as sign language, pictures and objects of reference, to gain their views.

People were involved in their care planning. End of life care planning and documentation guided staff in providing care at this important stage of people’s lives. End of life care was delivered empathetically and with respect and dignity.

People, their relatives and health care professionals had the opportunity to share their views about the service. Complaints made by people or their relatives were taken seriously and thoroughly investigated. The provider and registered manager were committed to continuously improve and had developed structures and plans to develop and consistently drive improvement within the service and maintain their care delivery to a good standard.

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 February 2019)

Why we inspected:

This was a planned inspection based on the previous rating.

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.

Avalon Nursing Home 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 Nursing Home provides nursing and personal care for up to 38 older people, some of whom were living with a dementia type illness. There were 27 people living at the home at the time of the inspection. In addition to living with dementia people had a range of complex health care needs which included stroke and diabetes. Most people required help and support from two members of staff in relation to their mobility and personal care needs.

Avalon Nursing Home is owned by Elderly Care Home Limited and is situated in Hampden Park in Eastbourne, East Sussex. Accommodation for people is provided over two floors with communal areas and a garden.

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 and associated regulations about how the service is run. Avalon Nursing Home had two registered managers at this time who work together to manage the service. The senior registered manager visits three days a week and the junior registered manager is in day to day charge.

We inspected Avalon Nursing Home in August 2015 where the overall rating for this service was Inadequate. We looked to see if improvements had been made in May 2016 and found that improvements had been made and breaches in regulation had been met. However, the improvements had not been fully embedded in practice and the service was rated as Requires Improvement. Due to a high number of concerns raised we brought our scheduled inspection to November 2016. We found people's safety was being compromised in a number of areas and the home was rated as Inadequate and was once again placed into special measures. We inspected again in July 2017 we found that improvements had been made across all areas of the service. But the breaches of Regulations 9, 11, 12, 17 and 18 were not fully met. We took appropriate enforcement action at that time. The provider had continued to provide CQC with monthly audits of the service delivery.

This inspection found that improvements had continued and that the rating for Safe and Effective improved to Good, Caring had remained Good and Responsive and Well led had remained as Requires Improvement. The breaches of regulation whilst met were not fully embedded into everyday care delivery and further time is needed to ensure that improvements are pro-actively sustained. The overall rating of this inspection is Requires Improvement.

There was continued commitment from the management team and staff to consistently strive for improvement. Areas identified as needing to improve at this inspection were immediately acted on and details of the actions taken were sent to CQC. This demonstrated that the management were responsive and wanted to improve their service.

The quality assurance system, audits and checks had not identified the shortfalls we found. Care plans did not consistently contain the detailed information staff needed to support people to meet their individual needs and care documentation was not consistently and accurately recorded. However, management had a good oversight of what was required to ensure the service continued to improve and meet the regulations. Staff told us they felt supported by the registered managers, they could talk to either of them and raise issues at any time. They felt listened to and knew any concerns would be taken seriously and acted on.

People were relaxed and comfortable with staff. They said they felt safe and there were sufficient staff to support them. One person said, “I feel safe, the staff are kind and look after me.” A relative said, “We visit everyday and we know she is safe.” When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector. Medicines were managed safely and in accordance with current regulations and guidance. There were systems that ensured medicines had been stored, administered, audited and reviewed appropriately. Risks associated with the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire or emergency situation. Staff were knowledgeable and trained in safeguarding adults and what action they should take if they suspected abuse was taking place. Accidents and incidents were recorded appropriately and steps taken to minimise the risk of similar events happening in the future.

Staff received training in order to undertake their role. Formal personal development plans, including two monthly supervisions and annual appraisals were in place. People were supported to make decisions in their best interests. The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The management and staff had attended training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and were aware of current guidance to ensure people were protected. DoLS applications had been made when required, to ensure people were safe and the registered manager was waiting for a response from local authority. People were encouraged and supported to eat and drink well. There was a varied daily choice of meals and people could give feedback and have choice in what they ate and drank. Health care was accessible for people and appointments were made for regular check-ups as needed.

People felt well looked after and supported. We observed friendly and genuine relationships had developed between people and staff. Care plans described people’s preferences and needs in relevant areas, including communication, and they were encouraged to be as independent as possible. People chose how to spend their day. Activities were mixed and people could choose either group activities or one to one. People were encouraged to stay in touch with their families and receive visitors. The provider had sent CQC notifications in a timely manner. Notifications are changes, events or incidents the service must inform us about.

Staff were asked for their opinions on the service and whether they were happy in their work. Staff said the management team was fair and approachable, care meetings were held every morning to discuss people's changing needs and how staff would meet these. Staff meetings were held monthly and staff could contribute to the meetings and make suggestions. Relatives said the management was very good; the registered manager was always available and they would be happy to talk to them if they had any concerns.

Avalon Nursing Home is owned by Elderly Care Home Limited and is situated in Hampden Park in Eastbourne, East Sussex. Accommodation for people is provided over two floors with communal areas and a garden. There were two lounges; one was called the nursing lounge and the other the Dennis Cullen wing.

At the time of this inspection there was no registered manager in post. An appointed manager was in post who was also a registered manager for another service owned by the provider. They had submitted their application to register with the CQC. 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 and associated regulations about how the service is run. After the inspection the manager became the registered manager following an interview with CQC.

At a comprehensive inspection in August 2015 the overall rating for this service was Inadequate. At this time we placed the service into special measures. Seven breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. The provider sent us an action plan and told us they would address these issues by February 2016.

During our inspection in May 2016, we looked to see if improvements had been made. The inspection found that improvements had been made and breaches in regulation had been met. However, the improvements had not been fully embedded in practice and they needed further time to be fully established in to everyday care delivery.

Due to a high number of concerns raised about the safety of people, care delivery, deployment of staff and staffing levels we brought forward a scheduled inspection to November 2016. We found people's safety was being compromised in a number of areas and the home was rated as Inadequate and was once again placed into special measures.

This inspection found that improvements had been made across all areas of the service. However, these improvements were not, as yet, all fully embedded in practice and need further time to be fully established in to everyday care delivery. The breaches of Regulations 9, 11, 12, 17 and 18 were not fully met.

There was a commitment from the manager and staff to continue with the improvements that had already taken place. The manager, provider and director acknowledged that this would take some time. They told us they wanted improvements to be fully embedded and would take their time to ensure this was done properly. Staff were now aware of their roles and responsibilities and had an understanding of the vision and direction of the home.

The quality assurance system, audits and checks had not identified all the shortfalls we found. Care plans did not consistently contain the detailed information staff needed to support people to meet their individual needs. However, the manager had a good oversight of what was required to ensure the service continued to improve and meet the regulations. Staff told us they felt supported by the manager, they could talk to her and raise issues at any time. They felt listened to and knew any concerns would be taken seriously and acted on.

Risks were not consistently managed safely. Systems were not in place to ensure people’s pressure relieving mattresses were set correctly and people were placed at risk through poor moving and handling practices.

There were enough suitably qualified and experienced staff to meet people's needs. However, these were not always deployed appropriately to ensure people’s needs could be attended to in a timely way. Recruitment procedures were not always followed to ensure staff were suitable to work at the home.

Staff understood the principles of the Mental Capacity Act 2005 (MCA) and any Deprivation of Liberty Safeguards (DoLS) applications had been submitted when required. However, there was no information about how people who lacked capacity were able to make decisions. There was no information about who could make decisions on people’s behalf.

There was a training and supervision programme. Staff received regular and ongoing training, however, staff competencies had not all been assessed and safe care delivery was not consistent.

People were given choices about what they wanted to eat and drink. They were supported to eat and drink a variety of food that met their individual needs and preferences. However, due to staff deployment some aspects of the mealtime experience still needed to be improved.

Care was not consistently person-centred. There were not enough meaningful activities for people to participate in throughout the day. People spent periods of time when they were unoccupied and unstimulated.

People were treated with dignity and respect. Staff were kind and caring. They knew people well and treated them with patience and compassion. We observed positive interactions taking place and people were supported to make their own choices.

People were supported to have access to healthcare services when they were needed them. There were systems to ensure people received their medicines safely, as prescribed. Staff had a good understanding of what steps to take to ensure people were protected from the risks of abuse.

The manager was working hard to develop an open and positive culture. This was focussed on ensuring people received good person-centred care that met their individual needs. The staff told us they felt supported and listened to by the manager. They understood the vision and direction of the home and the need for continued improvements.

We found a number of breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Avalon Nursing Home provides nursing and personal care for up to 38 older people, some of whom are living with a dementia type illness. There were 28 people living at the home at the time of the inspection. In addition to living with dementia people had a range of complex health care needs which included stroke, diabetes and Parkinson’s disease. Most people required help and support from two members of staff in relation to their mobility and personal care needs.

Avalon Nursing Home is owned by Elderly Care Home Limited and is situated in Hampden Park in Eastbourne, East Sussex. Accommodation for people is provided over two floors with communal areas and a garden.

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 and associated regulations about how the service is run.

At a comprehensive inspection in August 2015 the overall rating for this service was Inadequate. At this time we placed the service into special measures. Seven breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. We found there were not enough staff deployed to meet people’s needs. Staff had not received appropriate support or supervision. Staff did not understand their individual responsibilities in reporting safeguarding concerns. Where people did not have the capacity to consent, the registered person had not acted in accordance with legal requirements. The registered person had failed to notify the Care Quality Commission about any incidents that affected people who used the service. A notification is information about important events which the provider is required to tell us about by law. The premises were not always hygienic or safe to use. Care was task based rather than responsive to individual needs. People were not consistently treated with dignity and respect. The provider had not ensured that service users were protected from unsafe care and treatment by the quality assurance systems in place. We issued warning notices for these breaches. The provider sent us an action plan and told us they would address these issues by February 2016.

During our inspection in May 2016, we looked to see if improvements had been made. The inspection found that improvements had been made and breaches in regulation had been met. However the improvements were not fully embedded in practice and they need further time to be fully established in to everyday care delivery.

Due to a high number of concerns raised about the safety of people, care delivery, deployment of staff and staffing levels we brought forward the scheduled inspection to the 29 and 30 November 2016, so we could ensure that people were receiving safe care from sufficient numbers of suitably qualified staff.

At this inspection, people’s safety was being compromised in a number of areas. The provider had been unable to sustain the improvement made at the last inspection. Care plans did not reflect people’s assessed level of care needs and care delivery was not person specific or holistic. We found that people with specific health problems such as pressure ulcers and wounds were not all up to date and did not have sufficient guidance in place for staff to deliver safe treatment or prevent a re-occurrence. The lack of appropriate deployment and suitably qualified and experienced staff impacted on the care delivery and staff were under pressure to deliver care in a timely fashion. Shortcuts in care delivery were identified. We also found the provider was not meeting the requirements of the Mental Capacity Act (MCA) 2005. Mental capacity assessments were not completed in line with legal requirements. Staff were not following the principles of the MCA. We found there were restrictions imposed on people that did not consider their ability to make individual decisions for themselves, as required under the MCA Code of Practice.

The delivery of care suited staff routine rather than individual choice. Care plans lacked sufficient information on people’s likes and dislikes. Information in respect of people’s lifestyle choices was not readily available for staff. The lack of meaningful activities impacted negatively on people’s well-being.

People, staff and visitors were not always complimentary about the meal service at Avalon Nursing Home. They thought that sometimes food was not hot and one relative was concerned that their loved one was not being prompted to eat independently and losing their daily skills. Whilst another relative had had to remind staff that their loved one had been missed out when lunch and tea was served. The dining experience on the 29 November 2016 was not a social and enjoyable experience for people. People were not always supported to eat and drink enough to sustain their health and well-being.

Quality assurance systems were in place but had not identified the shortfalls in care delivery and record keeping. Incidents and accidents were recorded but there was no overview available that identified actions taken and plans to prevent a re-occurrence. We could not be assured that accidents and incidents were consistently investigated with a robust action plan to prevent a re-occurrence.

People’s medicines were stored safely and in line with legal regulations. However people did not always receive their medicines as prescribed. There were missing signatures for medicines. These had not been followed up to ensure that people received their prescribed medicines. We also found poor recording of topical creams, dietary supplements and ‘as required’ medication.

People and visitors we spoke with were complimentary about the caring nature of some of the staff, but said that the changes to staff, use of agency staff and staff leaving had impacted on how the home was run. Some people were supported with little verbal interaction, and some spent time isolated in their rooms.

Feedback had been sought from people, relatives and staff in 2015 but had not been undertaken since changes to the running of the home were implemented and the new management had been introduced. ‘Residents’ and staff meetings had been held on a regular basis which provided a forum for people to raise concerns and discuss ideas. However these had lapsed in the past six months.

Staff told us they thought that communication systems needed to be improved and they required more support to deliver good care. Their comments included “We work well but need to build up the staff team, we can’t do everything.”

People had access to appropriate healthcare professionals. Staff told us how they would contact the GP if they had concerns about people’s health. However care plans did not include all the information about people’s health related needs.

People were protected, as far as possible, by a safe recruitment system. Each personnel file had a completed application form listing their work history as wells as their skills and qualifications. Nurses employed by Avalon Nursing Home and bank nurses all had registration with the nursing midwifery council (NMC), which was up to date.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

We found a number of breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. CQC is now considering the appropriate regulatory response to resolve the problems we found.

We also found breaches in regulation where care and treatment had not been provided in a safe way. The premises were not always hygienic or safe to use. Care was task based rather than responsive to individual needs. People were not consistently treated with dignity and respect. The provider had not ensured that service users were protected from unsafe care and treatment by the quality assurance systems in place. We issued warning notices for these breaches. A warning notice includes a timescale by when improvements must be achieved. If a registered person has not made the necessary improvements within the timescale, we will consider further enforcement action. The provider sent us an action plan and told us they would address these issues by February 2016.

We undertook an inspection on 9 and 12 May 2016 to follow up on whether the required actions had been taken to address the previous breaches identified. We found significant improvements had been made. However, these improvements were not, as yet, fully embedded in practice and need further time to be fully established in to everyday care delivery.

Avalon Nursing Home provides nursing and personal care for up to 38 older people, some of whom are living with a dementia type illness. There were 28 people living at the home at the time of the inspection. In addition to living with dementia people had a range of complex health care

needs which included stroke, diabetes and Parkinson’s disease. Most people required help and support from two members of staff in relation to their mobility and personal care needs.

At the time of the inspection there was no registered manager at the home. There was a manager in post who had submitted an application to register with the Care Quality Commission (CQC) and were registered shortly after the inspection. 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.

There was a system in place to assess the quality of the service provided. The provider and manager were aware of the shortfalls we identified and were working to ensure improvements were made and embedded into everyday practice.

People were supported by staff who knew them well, were kind and caring and enjoyed looking after people. There was an emphasis on providing good person-centred care and getting to know and understand people as individuals. However, care plans did not always provide staff with the information they required to support people and did not always reflect the care people received. We observed staff had built a good rapport with people and responded to staff with smiles and affection.

There were a range of environmental and individual risk assessments in place to ensure people were looked after safely. However, information from risk assessments was not always used to update people’s care plans.

Mealtimes were an enjoyable and social occasion where people received the appropriate care and support they required.

Staff understood the principles of consent and the Mental Capacity Act (2005). Mental capacity assessments were in place and Deprivation of Liberty Safeguards (DoLS) had been submitted when required. However, best interest decision were not in place for everybody who needed them.

Staff had a good understanding of safeguarding; they were able to recognise different types of abuse and told us what actions they would take if they believed someone was at risk.

There were enough staff working each day to ensure people’s needs were met in an unhurried way. There was a robust recruitment procedure so only staff suitable to work at the home were employed.

During the inspection we looked at people's care records and associated documentation. We found that people had been protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records had been maintained.

The registered manager at Avalon works as the matron in the home, and is referred to as the matron throughout this report.

During our inspection we found that people had been respected and involved in decisions about their care and treatment. People were receiving appropriate care, treatment and support to meet their needs.

Meal choices were being offered which took into account peoples likes, dislikes, specific dietary needs, cultural and religious requirements. People had been referred to outside agencies appropriately, and care plans updated and reviewed.

A complaints policy and procedure was in place. A copy of the complaints procedure was displayed in the main entrance area. People we spoke with who lived in the home told us they would be happy to raise any concerns if they needed to.

Accurate records had not been maintained. We saw that some documentation did not include accurate, appropriate information in relation to the care and treatment provided to some people who lived in the home.

During our inspection we found that care and treatment was being provided to meet people's needs and personal preferences. People's views and experiences had been taken into account when planning care. The provider had effective measures in place to regularly assess and monitor the quality of service provided.