Avalon Residential Home

We found the following examples of good practice.

People were receiving visitors. Staff were following current national guidance for care homes. Arrangements were in place for this to happen in a way which reduced the risk of infection being introduced and spreading. People were also supported to remain in contact with those who mattered to them by telephone or using other technology.

People had been shielded if they had received a formal letter from their GP, although, everyone had been recognised as being at high risk to COVID-19 infection and appropriate measures were in place to protect them. People had been supported to self-isolate when they had symptoms of COVID-19. People and staff were socially distancing as much as was practicable.

People were admitted to the service safely. People were only accepted following a negative COVID-19 test result and then supported to self-isolate for 14 days following admission. One person told us they had been required to remain in their bedroom following their arrival at the home.

All staff wore PPE correctly (in line with national guidance for care homes). Staff had been provided with training on how to put PPE on and how to remove and dispose of it safely. Staff reminded people, when it was needed, why PPE was being worn and reassured people if they had any fears related to the use of PPE. Visitors were supported to use PPE correctly.

A testing regime was in place (in line with national guidance for care homes) to test people who lived in the service (with their consent), as well as staff and people’s designated visitors. The registered manager was aware of how to record and register these tests.

The environment was kept clean and laundry and waste managed safely. Staff followed cleaning schedules and used the appropriate products to clean and disinfect. Changes had been made to support enhanced infection, prevention and control, for example, additional wall mounted PPE storage and frequent cleaning of high touch surfaces such as door handles, rails and light switches.

The use of the building had been altered to support COVID-19 IPC arrangements, for example, one bedroom had been kept empty and was used as a staff room to support individual staff breaks and provide a place for staff to change their clothing before and after work.

Staff had received training on COVID-19 and on the additional IPC measures the service had introduced. They had also been trained to use additional heath assessment tools and equipment so they could identify quickly, those who may require medical support when poorly. Staff had worked together to ensure the service was staffed adequately, when the service experienced a COVID-19 outbreak. Staff had been supported to self-isolate as required and the use of the same agency staff had been limited.

The service’s policies and procedures had been updated to reflect current COVID-19 guidelines. A more detailed outbreak management plan was to be developed, using the knowledge now gained by the staff, of what went well and what practices they have altered and adapted as the pandemic has gone on. The registered manager had developed a detailed COVID-19 self-assessment tool, which they used to ensure they remained in line with national guidance and best practice. Infection control audits had been adapted to cover current pandemic practices and guidance.

The registered manager had used their COVID-19 outbreak experience to improve the service’s COVID-19 arrangements further and to provide support to a similar service during their outbreak.

Avalon Residential Home is a residential care home which can provide accommodation and personal care to 20 older people. At the time of the inspection 19 people were receiving care. The home also cares for people who live with dementia. People are accommodated in one adapted building.

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

We found following our previous inspection improvements had been made and sustained to the services quality monitoring systems and records. Any actions for ongoing improvement were identified and met. The home was well-led with a registered manager and senior staff providing strong leadership. A consistent and committed staff team was now in place. An open and transparent way of working was promoted with people, visitors and staff feeling they had access to the registered manager when they needed it.

A representative of the provider visited the home regularly to review the home’s performance and standard of service provided to people. Arrangements in place ensured the provider was also kept up to date in between visits with daily events and risks. The views of people, their representatives and professionals were sought and acted on to improve the service provided. The registered provider and registered manager understood their responsibilities and ensured relevant regulations were met.

People were kept safe from potential abuse and harm. Risks to their health and wellbeing were identified and action taken to reduce these risks. There were enough staff with the right skills and experience to meet people’s needs. One person said, “People (meaning staff) are always around, I feel safe.” People’s medicines were managed safely, and they received support to take their medicines as prescribed. Records relating to the management of medicines and the guidance available for staff, relating to people’s medicines, had been improved. The environment was kept clean, secure and well maintained.

People’s needs were assessed prior to moving in and ongoing thereafter. Community nurses supported staff to meet people’s health needs for example, wound care management and assessment for specialised equipment. People had access to GPs when needed. Staff received training and support, so they could deliver care in line with best practice guidance and the law. 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. One person said, “I’m able to make my own decisions.” We observed people enjoying their food. People’s nutritional needs and risks were identified and managed.

People were cared for in a kind, compassionate and respectful way. One person said, “It’s excellent, the assistants (the staff) are always helpful and cheerful.” One relative said, “They treat everyone the same, they don’t ignore them. However, many times someone asks something they (the staff) answer in a caring way, they have lots of patience.” People and their representatives were provided with information, in a format they could understand, to help them make informed decisions about their care. Staff worked in partnership with people and their representatives to ensure care was personalised. People’s specific preferences and wishes were known to staff who supported these.

People’s care was planned around their specific and individual needs. Staff in the home and visiting professionals, had access to up to date information about people’s needs and the support they required. This helped to ensure people received safe and appropriate ongoing support. Arrangements were in place for people and others to be able raise a complaint or discuss openly any concerns they may have. People were supported to take part in social activities. Staff were aware of people’s cognitive abilities and the potential risk of social isolation when living with dementia. People’s end of life wishes were explored with them and they were supported to have a dignified and comfortable death.

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 Requires Improvement (report published 13 July 2018) and there were two breaches of regulation. 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.

Why we inspected

This was a planned inspection based on the previous rating. The overall rating for the service has changed from Requires Improvement to Good. 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 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.

Avalon 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. ‘Avalon’, as it is referred to throughout this report, accommodates 20 people in one adapted building. It does not provide nursing care. At the time of the inspection 20 people were living there.

People were provided with single bedrooms across three floors, along with communal toilets and bathrooms. A passenger lift helped people access the upper floors. On the ground floor there were two lounges and a large dining room. There was wheelchair access to the front and back of the building. There was a garden and further outside space for people to enjoy. There was limited car parking on the property but this could be found in nearby surrounding roads

At our previous inspection on 14 and 16 February 2017 we identified three breaches of the Health and Social Care Act 2005 (Regulated Activities) Regulations 2014. People’s care and treatment was not always planned in a way which met their individual needs. Support was not always delivered in a way which helped to reduce risk to people. Care records were not always maintained accurately. The service’s quality monitoring systems had not effectively ensured compliance with all necessary regulations and had failed to make all the improvements required to the service.

Following our previous inspection we met with the provider to asked them to complete an action plan to show us what they would do to meet the requirements of the regulations. At this inspection we found people’s care had been planned and delivered to meet their individual needs. Risks to people had been identified and reduced and two of the three previously breached regulations had been met. However, management changes had delayed some improvements and we found people’s medicine administration records had not always been accurately maintained. Some aspects of the provider’s quality monitoring processes had improved, but a lack of robust governance had not led to improvements being embedded and sustained and further improvements were needed.

The improvements that had been made enabled the key questions, Is the service caring and responsive? to improve to Good. The key questions, Is the service safe, effective and well-led remain as Requires Improvement. This is the second inspection where the overall rating for the service has been Requires Improvement.

There should be a registered manager at Avalon. At the time of the inspection there was a new home manager who had been in post for six weeks. They were in the process of registering with the Care Quality Commission (CQC) to be the registered manager of Avalon. A registered manager is a person who has registered with the CCQ 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.

We found the new manager had a good understanding of the improvements needed and had already started taking action to address shortfalls. Processes and systems, including those used for quality monitoring, were being reviewed and either strengthened or altered to ensure they resulted in sustained improvements. A stronger senior management team was being developed so that staff could be provided with the support and direction they required. These staff were to be provided with the skills to challenge poor care and promote best practice. More regular meetings with different staff groups and people’s representatives were planned.

People were protected from abuse and discrimination because staff recognised what this looked like and knew how to report concerns they may have. Accidents and incidents were monitored and action taken to reduce the risks associated with these. The provider’s recruitment procedures were followed which protected people from staff who may not be suitable. Although there had been a large turnover in staff, there were enough staff to meet people’s diverse needs. Staff had received training but they required additional learning opportunities and support to improve their knowledge and skills. Guidance and support was being provided to promote best practice and additional training had been organised.

People were given help to make independent decisions and supported to have choice and control of their lives. They were supported in the least restrictive way possible. The policies and systems in the service supported this practice. Where people had been unable to consent to live at Avalon, their mental capacity, in respect of this, had been assessed. Where it had been found to be lacking applications for Deprivation of Liberty Safeguards (DoLS) had been submitted to the local county council by the provider. Care records about people’s daily care and treatment needed to better reflect the fact that some people were not always able to retain and weigh up information about their daily care and treatment and that staff made daily best interest decisions to keep them safe.

People’s nutritional wellbeing was monitored and those at risk of not maintaining this were provided with support. People had access to a GP and other health care professionals so their health needs could be met. Adaptions had been made to the environment to help people live safely and orientate themselves.

Staff were caring and responsive to people’s needs and they supported people to feel included and valued. People’s diverse needs were respected and they were supported to have a voice. People’s individual life histories, interests, likes, dislikes and preferences were explored. Staff used information about this to help personalise people’s care and to have better interactions with people. People’s privacy and dignity was maintained and information about them kept confidential.

People’s care needs were assessed and care plans devised for staff to follow. People were involved in planning and reviewing their care and their representatives, where appropriate, were able to contribute to this process. The content of care plans had improved and they contained accurate and relevant information about people’s needs.

People were supported to take part in activities of their choice, which they enjoyed and which were meaningful to them. There were arrangements in place for people to make a complaint and to have this resolved where possible. Relevant information was available to people and visitors and this could be provided in different formats.

People’s end of life wishes were explored with them, or an appropriate representative, so that staff could meet these at the right time. Staff provided care at the end of people’s lives which supported a dignified and comfortable death.

The service is registered to provide care to up to 20 people. It provides care to predominantly older people who required physical and psychological support with their daily living activities. Some people also live with a diagnosis of dementia.

There was a registered manager in position who was also the owner of the company. They visited the service three times a week. On a day to day basis a senior member of staff managed the service. This member of staff had applied to the Care Quality Commission to become the new 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.

During this inspection we identified breaches against three of the Health and Social Care Act 2005 (Regulated Activities) Regulations 2014. Regulation 9 Person – centred care was not met. People’s care and support was not always designed or delivered in a way which met their individual needs. Regulation 12 Safe care and treatment was not met. Risks to people were not always managed appropriately and mitigated. Regulation 17 Good governance was not met. People were at risk of receiving unsafe and inappropriate care because of poorly maintained care records. Also under the same regulation, the provider’s quality monitoring processes did not fully protect people from unsafe or inappropriate care and treatment. You can see what action we told the provider to take at the back of the full version of the report.

We also recommended the provider seek appropriate advice relating to one aspect of medicine administration guidance and the staff recruitment process.

People were not always kept safe. Improvements were needed to how risks to people’s health and welfare were managed. People received support to take their medicines however, additional guidance was required to ensure all administration practice was safe. Improvements were needed to the fire safety arrangements. A letter of non-compliance was subsequently issued by the Fire Safety Officer who will follow this up. People lived in a clean environment and there were infection control arrangements in place, although staff practice at times, potentially compromised these. A check was needed to ensure all necessary requirements with regard to this were in place and that these were being met. People were protected from potential abuse and discrimination because staff knew how to recognise these issues and report them. There were enough staff in number to meet the needs of the people, although how other tasks were organised needed improvement. Staff recruitment processes needed some improvement to ensure people were fully protected from those who may not be suitable to care for them.

People told us they felt well cared for. Staff had been provided with training, however, standards of practice varied. We did not always observe staff putting the principles of this training into practice. A more robust system of checking staffs’ competencies, knowledge and the effectiveness of the training provided was required. People received support with their eating and drinking and people’s weights and appetites were monitored. However, some people would have benefited from more staff awareness when this support was provided. The principles of the Mental Capacity Act (2005) were understood and adhered to. This ensured people received their care and treatment lawfully. Where possible people were supported to make their own decisions. People were supported to gain access to necessary health and social care practitioners when needed.

People’s care was delivered in a kind and caring way and people told us the staff were kind to them. People looked comfortable when staff were present and it was clear many had built up a good relationship with the staff that looked after them. Staff interactions with people were respectful, reassuring and mainly helpful. Staff listened to people and were patient with them. People’s anxiety or potential distress was picked up on by staff who took action to alleviate this. People were supported to make choices and where they were not able to do this any longer staff knew what people’s preferences were and they tried to uphold these. Family members were welcomed. They were involved and consulted about their relative’s care, where this was appropriate to do so. They were kept informed of any changes regarding their relatives' health and welfare. On the whole people’s privacy and dignity was maintained, however, how people’s hairdressing needs were met compromised this.

People’s care plans lacked accuracy and were not always relevant. At times people’s care was not delivered according to the written care plan. People however, told us they liked the way they received their care. Staff provided people’s personal care in a way which recognised people’s choices and preferences. Staff were not as responsive as they could be to some people’s other specific and individual needs. Although social activities were planned and provided these were poorly organised and executed during the inspection. This limited people’s opportunities to spend time with staff and receive the support they needed to take part in meaningful activities. There were arrangements in place for people to raise a complaint and have this acknowledged and addressed.

Staff had not received strong enough leadership. They had not always been supportive of the management arrangements and this had led to policies, procedures and expectations not being fully understood and followed. Action taken had started to address this. Although most people and relatives considered the management staff to be visible and approachable, this was not everyone's view. One relative did not consider their feedback to be listened to or acted on sufficiently enough for them to see improvements in the service. The provider’s quality monitoring system, at times, identified shortfalls which were addressed and which then resulted in improvements being made. However, this was also not always the case and the processes were not robust enough to ensure full compliance with relevant regulations. The provider was looking at ways of improving how they obtained feedback from people, their relatives and staff.