Avery Lodge Residential Home

Avery Lodge Residential Home is a residential care home. At the time of the inspection is was providing personal care to 14 older people with mental health issues. The service had no vacancies. It is an adapted period building with accommodation over two floors.

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

The service had made improvements since our last inspection and need to continue to do so. At the time of the inspection, several stakeholders had been working with the service and both they, the people we spoke with who used the service and staff confirmed improvements had been made. However, some concerns were still evident although the service is no longer in breach of the Health and Social Care Regulations 2008 (regulated Activities) 2014. The provider needs to continue to develop its quality monitoring system and its approach to governance. This needs to include an understanding of why actions are taken in relation to the impact it has on the quality and safety of the service, rather than just be a paper exercise. If you decide to go down a recommendation route, you could put that here?

The service had failed to rectify identified hot water temperatures that were above safe levels. This was actioned shortly after our inspection. Incidents and accidents had been investigated and appropriate actions taken but the service had no formal mechanism in place to analyse these for trends to mitigate against reoccurrence. The other risks to people, both on an individual basis and as a group, had been identified, assessed and mitigated. People received their medicines as prescribed and there were enough staff to meet people’s needs. Processes were in place to help protect people against the risk of abuse.

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. However, documentation regarding these practices needed to be improved. Although the service had made some improvements to the environment, further refurbishment was required, and a plan was in place to achieve this. We have made a recommendation regarding this. People benefitted from receiving support from staff who had been trained and supported and demonstrated the skills required. They worked in partnership with others to ensure people received effective and appropriate care including to meet nutritional and healthcare needs.

People told us they were supported by staff who were caring, patient and listened to them. They felt respected and involved in the care they received. Staff knew people well and used their knowledge of people’s histories to form meaningful relationships. People told us staff knew them, and their individual needs, and met those needs to their preference. People’s dignity was maintained, and people were encouraged to remain as independent as possible including accessing the community.

People’s past lives, and experiences, had been considered when planning care and delivering it. Care plans were person-centred and contained detailed information on people’s histories and relationships which helped staff deliver care individual to each person. People’s needs had been regularly reviewed and people important to them had been included in that. Where people had communication needs, these had been met. Although we saw no formal activities going on during our inspection, we saw that staff had time to fully engage with people and that individuals accessed the community or garden and spent time engaged with others. People told us they had no complaints about the service they received however, the service had processes in place should people need to raise concerns. These processes considered the need for a quick resolution and the need for openness, discussion and transparency.

People told us they were happy living in the home and with the care they received. Staff worked well as a team and felt valued, supported and able to contribute ideas. People’s views had been sought and they were involved in the running of the service. Relationships had been built with other professionals and this had improved the service people received.

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 12 July 2018) and there were two breaches of regulations. 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 improvements had been made and the provider was no longer in breach of regulations.

The last rating for this service was requires improvement. The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Avery Lodge Residential Home on our website at www.cqc.org.uk.

Follow up

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

At our last inspection on 17 and 18 January 2017, we found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the management had failed to have effective systems and processes in place to monitor the safety and quality of the service provided. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of effective, responsive, and well-led, to at least good.

At this May 2018 inspection we found a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to the governance of the service, and one new breach in relation to consent procedures.

Avery Lodge residential 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.

The care home accommodates 14 people in one adapted building. At the time of this inspection there were 13 people living in the service, some of whom were living with dementia.

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.

The registered manager had not ensured that all areas identified as requiring improvement at our previous inspection were completed promptly.

The registered manager had applied for Mental Capacity Act 2005 Deprivation of Liberty Safeguards (MCA DoLS) when people who lacked capacity to consent, had their liberty restricted. However, we did not see that a capacity assessments had been carried out in advance to determine that this was required, or how any restrictions would be managed. Consent forms relating to decisions about people’s care were generic to several people living in the service, and had not been reviewed since 2016.

There were audits in place to monitor the quality of the service provided, however, there was still no care plan audit to check the quality of the content. People’s records still did not show that they had been involved in the planning of their care, and review procedures were not robust or meaningful.

Risk assessments were completed to ensure that people were kept safe. However, we found that the level of information was not sufficient to ensure that staff had up-to date and clear guidance to help them support people safely.

Care plans were not person centred due to the format being used. The registered manager acknowledged improvement was needed, and had sourced a template which would allow for more person centred detail to be added. These were being implemented.

Staffing levels were not always sufficient to meet people’s physical, emotional and social needs. The registered manager had identified a need for additional hours during the day and was trying to recruit.

Activities were provided by care staff when time allowed. More detailed information on people's social care needs was required to inform individual needs and preferences for social activity, and we have made a recommendation about this.

The provider had improved some areas of the service to modernise rooms, and ensure decoration was updated. The provider told us that people were happy with the 'homely' environment and current decoration in the service. However, we advised that they reviewed some areas of the premises for the benefit of people living with dementia, and we have made a recommendation about this.

People’s end of life wishes were sought and advance care plans were in place.

People who used the service had access to regular health care input, and advice given by health care professionals was followed appropriately.

Records showed people living at the service received their medicines as prescribed. Some improvement was needed to ensure documentation was clear, and the registered manager implemented the changes promptly.

Staff respected people's privacy and dignity and interacted with people in a caring manner. However, some feedback from people indicated the staff approach was variable.

Systems were in place which safeguarded people from the potential risk of abuse. Staff understood their roles and responsibilities in keeping people safe.

People and relatives said if they needed to make a complaint they would know how to. There was a complaints procedure in place for people to access if they needed to. The views of people, relatives and staff were sought via an annual survey.

The inspection took place on 17 and 18 January 2017 and was unannounced.

Avery Lodge is registered to provide care for up to 14 people. At the time of the inspection 13 people were living at the home. The home supports older people some of whom are living with some forms of dementia or who have other mental health needs. The accommodation comprised of a largely Victorian building over two floors. The service was currently using one room as a shared room.

There was a manager in place. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in June 2015, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to safe care and treatment and the need for consent. People’s medicines were not being stored safely and they were not always being administered in a safe way. The appropriate procedures were not being followed when some people’s liberty was being restricted. Best interest decisions were being made without following the guidelines of the mental capacity act.

At this inspection on 17 and 18 January 2017 we found improvements had been made in these areas, so the service was no longer in breach of these regulations. However at this inspection we found a new breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The manager did not have systems in place to effectively monitor the quality of care provided by staff. Staff training was not robustly monitored and staff knowledge was not tested to ensure the training they received had been effective. We found staff were not consistently responsive to people’s needs and staff didn’t always provide support to people in a person centred way. The manager did not have effective systems to ensure good practice was consistently embedded in the care provided. The shortfalls in governance arrangements constituted a breach of Regulation 17 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 full version of the report.

People did not have accurate and detailed reviews so people were not able to give constructive feedback about the care they received. People’s assessment records did not always fully detail people’s needs and risks. Records were not always audited to ensure they were of a good quality.

Staff did not have enough time to spend chatting to people or to engage with people in one to one activities throughout the day. The manager had not considered ways to encourage social stimulation other than planned events.

We have made a recommendation about the service putting systems in place to supervise and oversee staff practice.

The Care Quality Commission (CQC) is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. The service was depriving some people of their liberty in order to provide necessary care and to keep them safe. The service had made applications for authorisation to the local authority DoLS team. The service was working within the principles of the MCA. Staff had a good understanding about the need to seek consent from the people they were supporting.

We have made a recommendation about improving staff’s knowledge of DoLS.

People benefited from being supported by staff who were safely recruited. There was consistently enough staff to safely meet people’s physical needs at the time of this inspection.

The manager and staff understood how to protect people from the risk of abuse and harm. However, staff were not aware of outside agencies they could also report their concerns to.

People received their medicines in a safe way. People’s medicines were stored securely. The administration of people’s medicines was audited and checked. The manager and staff were proactive in responding to a change in people’s health needs. The manager and staff knew about the risks which people faced and how to respond to these. The manager ensured that the environment and equipment used was safe.

People who we could communicate with told us they were treated in a caring and kind way by staff. People’s privacy was respected. The manager encouraged people to maintain relationships with those who were important to them. Some people accessed the community when they wanted to and the manager provided planned events tailored to people’s likes.

The manager made real efforts to create an upbeat atmosphere at Avery Lodge.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

This is a summary of what we found-

Is the service safe?

People we spoke with told us that the felt safe at the service. One person told us, "I am very happy, I really have no complaints at all. I can go into Great Yarmouth when I want to, I am well fed and well looked after." Another person we spoke with said," I am happy and I am safe. I feel well looked after and there is nothing I want for."

Risk assessments were in place to ensure that people were safe when out in the community and a mobile phone containing emergency contact numbers always available for people to take out with them. We saw that personal evacuation plans and safety measures were in place to be used in the event of emergencies.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

Is the service effective?

People told us that they were happy with their care. Care records we looked at were up to date to ensure that staff had current information about the people they supported and showed that people's health and social care needs were being met.

The recruitment processes that were followed by the provider were not always effective. They did not ensure that the necessary information and detail was in place.

Quality assurance measures were in place to identify the effectiveness of the service. This included surveys of people who used the service, relatives, staff and visiting professionals and audits of infection control measures and medication. Details of further management checks that had just been introduced were shown to us. These will further improve the effectiveness of the service.

Is the service caring?

People who used the service told us that they were well cared for. They were happy with the staff team and with the care provided. They told us that the food was good with a choice available. Two people we spoke with told us that they liked spicy food and the chef, 'Often makes us a nice curry.' We also spoke with a relative visiting at the time of our inspection. They were very satisfied with the overall care and support their family member received. They told us that they thought 'The care is excellent, all my requests for information are answered and the care team are brilliant. My (relative) is treated with dignity and respect at all times.'

Is the service responsive?

Records showed that an assessment of people's needs was completed before they moved to the service. This showed the person's assessed needs and linked to their care plan, which detailed how those needs were to be met.

People were able to access community facilities outside of the service and were supported by staff when necessary. Some people went to their local church, shops, pubs and restaurants independently and were supported in maintaining this independence.

Is the service well-led

The service was managed by one of the owners. However, at the time of the inspection an application was still awaited to formalise their registration.

The owners lived on the premises and were available at any time in the event of a problem. Arrangements were in place for either additional staffing at night or alternative on call facilities when the owners were not available.

Staff we spoke with told us that they felt well supported and records showed that regular supervision was now taking place.

We looked at the care records held by the service. These were comprehensive, but some areas requiring improvement were noted. We also looked at staff recruitment and training records and maintenance records which were all clear and well managed.

Robust recruitment procedures were followed to ensure that suitable staff were taken on to support and care for people who used the service.

People who used the service told us the care they received was very good. One person described it as, "Brilliant." Another person told us that staff, "Always check to see if I need medication and watch me while I take it." We were told the food was very good, and one person told us they had, "No complaints at all."

The staff we spoke with told us about training they received to help with their job including induction training for new starters.